Peds/OB Practice ?s Quiz II

Davis: A nurse remarks to a 38-week-gravid client, "It looks like your face and hands are swollen." The client responds, "Yes, you're right. Why do you ask?" The nurse's response is based on the fact that the changes may be caused by which of the following? 1. Altered glomerular filtration. 2. Cardiac failure. 3. Hepatic insufficiency. 4. Altered splenic circulation.

1. Altered glomerular filtration.

Davis: A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following for items. Which of the orders should the nurse preform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.

1. Assess deep tendon reflexes.

Davis: A pregnant diabetic has been diagnosed with polyhydramnios. Which of the following would explain this finding? 1. Excessive fetal urination. 2. Recurring hypoglycemic episodes. 3. Fetal sacral agenesis. 4. Placental vascular damage

1. Excessive fetal urination.

A nurse is discussing diet with a pregnant woman. Which of the following foods should the nurse advise the client to avoid consuming during her pregnancy? 1. Bologna 2. Cantaloupe 3. Asparagus 4. Popcorn

1. Bologna.

Davis: A nurse is discussing diet with a pregnant woman. Which of the following foods should the nurse advise the client to avoid consuming during her pregnancy? 1. Bologna. 2. Cantaloupe. 3. Asparagus. 4. Popcorn.

1. Bologna.

Davis: A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? 1. Breech presentation. 2. Station -3. 3. Oligohydramnios. 4. Dilation 2 cm. 5. Transverse Lie.

1. Breech presentation. 2. Station -3. 5. Transverse Lie.

Davis: A hospitalized gravida's blood work is hematocrit 30% and hemoglobin 10 gm/dL. In light of the laboratory data, which of the following meal choices should the nurse recommend to this patient? 1. Chicken livers, sliced tomatoes, and dried apricots. 2. Cheese sandwich, tossed salad, and rice pudding. 3. Veggie burger, cucumber salad, and wedge of cantaloupe. 4. Bagel with cream cheese, pear, and hearts of lettuce

1. Chicken livers, sliced tomatoes, and dried apricots.

Davis: Which of the following long-term goals is appropriate for a client, 10 weeks' gestation, who is diagnosed with gestational trophoblastic disease (hydatiform mole)? 1. Client will be cancer-free 1 year from diagnosis. 2. Client will deliver her baby at full term without complications. 3. Client will be pain-free 3 months after diagnosis. 4. Client will have normal hemoglobin and hematocrit at delivery.

1. Client will be cancer-free 1 year from diagnosis.

Davis: A child has been diagnosed with rubella. What must the pediatric nurse teach the child's parents to do? 1. Notify any exposed pregnant friends. 2. Give penicillin po every 6 hours for 10 full days. 3. Observe the child for signs of respiratory distress. 4. Administer diphenhydramine every 4 hours as needed.

1. Notify any exposed pregnant friends.

ATI: A nurse in a prenatal clinic is providing education to a client who is in the 8th week of gestation. The client states that she does not like milk. What is a good source of calcium that the nurse can recommend to the client? 1. Dark green, leafy vegetables. 2. Deep red or orange vegetables. 3. White breads and rice. 4. Meat, poultry, and fish.

1. Dark green, leafy vegetables.

A nurse who is providing nutrition counseling to a new gravid client, advises the woman that a serving of meat is approximately equal in size to which of the following items? 1. Deck of Cards. 2. Paperback book. 3. Clenched Fist. 4. Large tomato.

1. Deck of cards

Davis: A nurse, who is providing nutrition counseling to a new gravid client, advises the woman that a serving of meat is approximately equal in size to which of the following items? 1. Deck of cards. 2. Paperback Book. 3. Clenched Fist. 4. Large tomato.

1. Deck of cards.

ATI: A nurse o the obstetrical unit is admitting a client who is in labor. the client has a positive HIV status. The nurse is aware that which of the following is contraindicated for this client? Select all that apply. 1. Episiotomy 2. Vacuum Extraction 3. Forceps 4. Cesarean birth 5. Internal Fetal Monitoring

1. Episiotomy 2. Vacuum Extraction 3. Forceps 5. Internal Fetal Monitoring

Davis: A 39-year-old, 16-week-gravid woman has had an amniocentesis. Before discharge, the nurse teaches the woman to call her doctor if she experiences any of the following side effects? Select all that apply. 1. Fever or chills. 2. Lack of fetal movement. 3. Abdominal pain. 4. Rash or pruritus. 5. Vaginal bleeding.

1. Fever or chills. 2. Lack of fetal movement. 3. Abdominal pain. 5. Vaginal bleeding.

Davis: Which of the following clients is at highest risk for developing a hypertensive illness of pregnancy? 1. G1P0000, age 44 with history of diabetes mellitus. 2. G2P0101, age 27 with history of rheumatic fever. 3. G3P1102, age 25 with history of scoliosis. 4. G3P1011, age 20 with history of celiac disease.

1. G1P0000, age 44 with history of diabetes mellitus.

ATI: A nurse is assessing an infant who has eczema. Which of the following are clinical manifestations of eczema in an infant? Select all that apply. 1. Generalized distribution. 2. Papules. 3. Clusters. 4. Crusting lesions. 5. Lichenification.

1. Generalized distribution. 2. Papules. 4. Crusting lesions.

ATI: A nurse is providing teaching ab out expected changes during puberty to a group of parents of early adolescent girls. Which of the following statements by one of the parents indicates an understanding of the teaching? 1. Girls usually stop growing about 2 years after menarche. 2. Girls are expected to gain about 65 pounds during puberty. 3. Girls experience menstruation prior to breast development. 4. Girls typically grow more than 10 inches during pubert.

1. Girls usually stop growing about 2 years after menarche.

Davis: A client with 4 protein and 4 reflexes is admitted to the hospital with severe preeclampsia. The nurse must closely monitor the woman for which of the following? 1. Grand mal seizure. 2. High platelet count. 3. Explosive diarrhea. 4. Fractured pelvis.

1. Grand mal seizure.

Davis: In anticipation of a complication that may develop in the second half of pregnancy, the nurse teaches an 18-week gravid client to call the office if she experiences which of the following? 1. Headache and decreased output. 2. Puffy feet. 3. Hemorrhoids and vaginal discharge. 4. Backache.

1. Headache and decreased output.

Davis: A gravid woman has sickle cell anemia. Which of the following situations could precipitate a vaso-occlusive crisis in this woman? 1. Hypoxia. 2. Alkalosis. 3. Fluid overload. 4. Hyperglycemia.

1. Hypoxia

ATI: A nurse is caring for a postpartum client. the nurse should understand that which of the following findings are the earliest indication of hypovolemia caused by hemorrhage. 1. Increasing pulse and decreasing BP 2. Dizziness and increasing respiratory rate 3. Cool, clammy skin, and pale mucous membranes. 4. Altered mental status and level of consciousness.

1. Increasing pulse and decreasing BP.

Davis: A type 1 diabetic is being seen for preconception counseling. The nurse should emphasize that during the first trimester the woman may experience which of the following? 1. Need for less insulin than she normally injects. 2. An increased risk for hyperglycemic episodes. 3. Signs and symptoms of hydramnios. 4. A need to be hospitalized for fetal testing.

1. Need for less insulin than she normally injects.

ATI: A nurse is caring for a client at 14 weeks of gestation who has hyperemesis gravidarum. the nurse is aware that which of the following are risk factors for the client? Select all that apply. 1. Obesity. 2. Multifetal Pregnancy. 3. Maternal age greater than 40. 4. Migraine Headache 5. Oligohydramnios

1. Obesity. 2. Multifetal Pregnancy. 4. Migraine Headache

Davis: A gravid woman, 36 weeks' gestation with type 1 diabetes, has just had a biophysical profile (BPP). Which of the following results should be reported to the obstetrician? 1. One fetal heart acceleration in 20 minutes. 2. Three episodes of fetal rhythmic breathing in 30 minutes. 3. Two episodes of fetal extension and flexion of 1 arm. 4. One amniotic fluid pocket measuring 3 cm.

1. One fetal heart acceleration in 20 minutes.

ATI: A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following should be included in the discussion. Select all that apply. 1. Precipitous delivery 2. Lacerations 3. Inversion of the uterus 4. Oligohydramnios 5. Retained placental fragments

1. Precipitous delivery 2. Lacerations 3. Inversion of the uterus 5. Retained placental fragments

Davis: Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings.

1. Put the client in the knee chest position.

ATI: A nurse is caring for a child who has contact dermatitis due to poison ivy. Which of the following should be included in the plan of care? Select all that apply. 1. Remove the clothing over the rash. 2. Initiate contact isolation precautions. 3. Expose the rash to a heat lamp for 15 minutes. 4. Cleanse the affected skin with hydrogen peroxide solution. 5. Apply calamine lotion to the skin.

1. Remove the clothing over the rash. 5. Apply calamine lotion to the skin.

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? Select all that apply. 1. Respirations fewer than 12/min 2. Urinary output less than 30 mL/hr 3. Hyperrelexic deept-tendon reflexes 4. Decreased level of consciousness 5. Flushing and sweating.

1. Respirations fewer than 12/min 2. Urinary output less than 30 mL/hr 4. Decreased level of consciousness

Davis: The physician has ordered a nonstress test (NST) to be done on a 41-weekgestation client. During the 1⁄2 hour test, the nurse observed three periods of fetal heart accelerations that were 15 beats per minute above the baseline and that lasted 15 seconds each. No contractions were observed. Based on these results, what should the nurse do next? 1. Send the client home and report positive results to the MD. 2. Perform a nipple stimulation test to assess the fetal heart in response to contractions. 3. Prepare the client for induction with IV oxytocin or endocervical prostaglandins. 4. Place the client on her side with oxygen via face mask

1. Send the client home and report positive results to the MD.

Davis: A woman's glucose challenge test (GCT) results are 155 mg/dL at 1 hour post- glucose ingestion. Which of the following actions, as ordered by the physician, is appropriate? 1. Send the woman for a glucose tolerance test. 2. Teach the woman how to inject herself with insulin. 3. Notify the woman of the normal results. 4. Provide the woman with oral hypoglycemic agents.

1. Send the woman for a glucose tolerance test.

Davis: A client is admitted to the hospital with severe preeclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform? 1. Strike the woman's patellar tendon. 2. Palpate the woman's ankle. 3. Dorsiflex the woman's foot. 4. Position the woman's feet flat on the floor

1. Strike the woman's patellar tendon.

Davis: The laboratory reported the L/S ratio results from an amniocentesis as 1:1. How should the nurse interpret the result? 1. The baby is premature. 2. The mother is high risk for hemorrhage. 3. The infant has kernicterus. 4. The mother is high risk for eclampsia.

1. The baby is premature

Davis: A nurse who is caring for a pregnant diabetic should carefully monitor the client for which of the following? Select all that apply. 1. Urinary tract infection. 2. Multiple gestation. 3. Metabolic acidosis. 4. Pathological hypotension. 5. Hypolipidemia.

1. Urinary tract infection. 3. Metabolic Acidosis.

Davis: The nurse is caring for a pregnant client who is a vegan. Which of the following foods should the nurse suggest the client consume as substitutes for restricted foods? 1. Tofu, legumes, broccoli. 2. Corn, yams, green beans. 3. Potatoes, parsnips, turnips. 4. Cheese, yogurt, fish.

1. Tofu, legumes, broccoli.

The nurse is caring for a pregnant patient who is a vegan. Which of the following foods should the nurse suggest the patient consume as substitutes for restricted foods? 1. Tofu, legumes, broccoli. 2. Corn, yams, green beans. 3. Potatoes, parsnips, turnips. 4. Cheese, yogurt, fish.

1. Tofu, legumes, broccoli.

A pregnant patient is lactose intolerant. Which of the following foods could this woman consume to meet her calcium needs?

1. Turnip Greens

Davis: A pregnant client is lactose intolerant. Which of the following foods could this woman consume to meet her calcium needs? 1. Turnip greens. 2. Green beans. 3. Cantaloupe. 4. Nectarines.

1. Turnip Greens.

A 13 year old boy is hospitalized for a femur fracture. He was hit by a car while he and his friends were racing bikes near a major intersection. The childs parents are concerned about his judgement. The nurse should tell the parents that the behavior is: 1. Typical of young teens. 2. Related to hormonal surges during adolescence. 3. An isolated incident and will not likely happen again. 4. Related to teen rebellion.

1. Typical of young teens.

Which method is the most effective way to present an education program on abstinence to adolescents? 1. Use peer led programs that emphasize consequences of unprotected sexual contact. 2. Teach students methods to resist peer pressure. 3. Offer students the opportunity to care for a simulator infant for 1 week. 4. Offer statistics, pamphlets, and films discussing the consequences of unprotected sexual contact.

1. Use peer led programs that emphasize consequences of unprotected sexual contact.

Davis: A type 1 diabetic client has developed polyhydramnios. The client should be taught to report which of the following? 1. Uterine contractions. 2. Reduced urinary output. 3. Marked fatigue. 4. Puerperal rash.

1. Uterine Contractions.

Which should the nurse recommend to the parents of a 9 year old hospitalized following a bicycle injury? To prevent future injury, their child should: 1. Wear safety equipment while riding bicycles. 2. Read educational material on bicycle safety. 3. Watch a video on bicycle safety. 4. Ride his bike in the presence of adults.

1. Wear safety equipment while riding bicycles.

Davis: The nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? 1. Weight loss. 2. 2 proteinuria. 3. Decrease in plasma protein. 4. 3 patellar reflexes.

1. Weight Loss.

Davis: A 32-week-gestation client was last seen in the prenatal client at 28 weeks' gestation. Which of the following changes should the nurse bring to the attention of the certified nurse midwife? 1. Weight change from 128 pounds to 138 pounds. 2. Pulse rate change from 88 bpm to 92 bpm. 3. Blood pressure change from 120/80 to 118/78. 4. Respiratory rate change from 16 rpm to 20 rpm.

1. Weight change from 128 pounds to 138 pounds.

Davis: A woman tells the nurse that she would like suggestions for alternate vitamin C sources because she isn't very fond of citrus fruits. Which of the following suggestions is appropriate? 1. Barley and brown rice. 2. Strawberries and potatoes. 3. Buckwheat and lentils. 4. Wheat flour and figs.

2. Strawberries and potatoes.

ATI: A nurse is caring for an infant who has diaper dermatitis. Which of the following should be included in the plan of care? Select all that apply. 1. Apply talcum powder with every diaper change. 2. Allow the buttocks to air dry. 3. Use commercial baby wipes to cleanse the are. 4. Use the cloth diapers until the rash is gone. 5. Apply zinc oxide ointment to the affected area.

2. Allow the buttocks to air dry. 5. Apply zinc oxide ointment to the affected area.

Davis: A 25-week-pregnant client, who had eaten a small breakfast, has been notified that her glucose challenge test results were 132 mg/dL 1 hour after ingesting the glucose. Which of the following is appropriate for the nurse to say at this time? 1. "Because you ate before the test, the results are invalid and will need to be repeated." 2. "Because your test results are higher than normal, you will have to have another more specific test." 3. "Because of the results you will have to have weekly glycohemoglobin testing done." 4. "Because your results are within normal limits you need not worry about gestational diabetes."

2. "Because your test results are higher than normal, you will have to have another more specific test."

Davis: A client, G2P1001, telephones the gynecology office complaining of left-sided pain. Which of the following questions by the triage nurse would help to determine whether the one-sided pain is due to an ectopic pregnancy? 1. "When did you have your pregnancy test done?" 2. "When was the first day of your last menstrual period?" 3. "Did you have any complications with your first pregnancy?" 4. "How old were you when you first got your period?"

2. "When was the first day of your last menstrual period?"

The nurse is evaluating the 24 hour dairy intake of four gravid clients. Which of the following clients consumed the highest number of dairy servings during 1 day. The client who consumed: 1. 4 oz whole milk, 2 oz hard cheese, 1 cup of pudding made with milk and 2 oz cream cheese. 2. 1 cup yogurt, 8 oz chocolate milk, 1 cup cottage cheese, and 1 1/2 oz hard cheese. 3. 1 cup cottage cheese, 8 oz whole milk, 1 cup buttermilk, 1/2 oz hard cheese. 4. 1/2 cup frozen yogurt, 8 oz skim milk, 4 oz cream cheese and 1 1/2 cup cottage cheese.

2. 1 cup yogurt, 8 oz chocolate milk, 1 cup cottage cheese, and 1 1/2 oz hard cheese. hich of the following choices can the nurse teach a prenatal client is eq

A nurse is discussing the serving sizes in the grain food group with a new prenatal client. Which of the following foods equals 1 ounce serving size from the grain group? 1. 1 bagel. 2. 1 slice of bread. 3. 1 cup cooked pasta. 4. 1 tortilla. 5. 1 cup dry cereal.

2. 1 slice of bread. 4. 1 tortilla. 5. 1 cup dry cereal.

Davis: Which of the following choices can the nurse teach a prenatal client is equivalent to one 2 oz protein serving. 1. 4 tbsp peanut butter 2. 2 eggs. 3. 1 cup cooked lima beans. 4. 2 ounces mixed nuts.

2. 2 eggs.

Which of the following choices can the nurse teach a prenatal client is equivalent to one 2 oz protein serving? 1. 4 tbsp peanut butter 2. 2 eggs. 3. 1 cup cooked lima beans. 4. 2 ounces mixed nuts.

2. 2 eggs.

A 16 year old is having a discussion with the nurse about the teens recent diagnosis of lupus. In explaining the childs prognosis, the nurse uses the knowledge that adolescents are: 1. Preoccupied with thoughts of the here and now. 2. Able to understand and imagine possibilities for the future. 3. Capable of thinking only in concrete terms. 4. Overly concerned with past events and relationships.

2. Able to understand and imagine possibilities for the future.

Davis: A woman with a diagnosis of ectopic pregnancy is to receive medical intervention rather than a surgical interruption. Which of the following intramuscular medications would the nurse expect to administer? 1. Decadron (desamethasone). 2. Amethopterin (methotrexate). 3. Pergonal (menotropins). 4. Prometrium (progesterone).

2. Amethopterin (methotrexate).

Davis: A gravid client, 27 weeks' gestation, has been diagnosed with gestational diabetes. Which of the following therapies will most likely be ordered for this client? 1. Oral hypoglycemic agents. 2. Diet control with exercise. 3. Regular insulin injections. 4. Inhaled insulin.

2. Diet control with exercise.

ATI: A nurse in the ED is caring for a client who reports abrupt, sharp, right sided lower quadrant abdominal pain and bright red vaginal bleeding. the client states she missed on menstrual cycle and cannot be pregnant because she has an intrauterine deice. The nurse should suspect which of the following? 1. Missed abortion. 2. Ectopic Pregnancy. 3. Severe Preeclampsia. 4. Hydatidiform Mole

2. Ectopic Pregnancy.

A 16 year old is hospitalized for CF. He will be an inpatient for 2 weeks while he receives IV antibiotics. Which action taken by the nurse will most enhance his psychosocial development? 1. Fax the teens teacher, and have her send in his homework. 2. Encourage the teens friends to visit him in the hospital. 3. Encourage the teen's grandparents to visit frequently. 4. Tell the teen he is free to use his phone to call or text friends.

2. Encourage the teens friends to visit him in the hospital.

To obtain an adolescent's health information, the nurse should: 1. Interview the adolescent using direct questions. 2. Gather information during a casual conversation. 3. Interview the adolescent only in the presence of the parents. 4. Gather information only from the parents.

2. Gather information during a casual conversation.

Davis: An obese gravid woman is being seen in the prenatal clinic. The nurse will monitor this client carefully throughout her pregnancy because she is high risk for which of the following complications of pregnancy? Select All that apply. 1. Placenta previa. 2. Gestational diabetes. 3. Abruptio placentae. 4. Preeclampsia 5. Chromosomal defects

2. Gestational Diabetes 4. Preeclampsia

Davis: Which of the following findings should be reported to the primary health care practitioner when assessing a first-trimester gravida suspected of having gestational trophoblastic disease (hydatiform mole)? Select all that apply. 1. Hematocrit 39%. 2. Grape-like clusters passed from the vagina. 3. Markedly elevated blood pressure. 4. White blood cell count 8000/mm3. 5. Hypertrophied breast tissue.

2. Grape-like clusters passed from the vagina. 3. Markedly elevated blood pressure.

A 9 year old girl builds a clubhouse in her backyard. She hangs a sign that says "no boys allowed" printed on it. The child's parents are concerned that she is excluding their neighbor's son, and they are upset. What should the school nurse tell the child's parents? 1. Her behavior is cause for concern and should be addressed. 2. Her behavior is common among school age children. 3. Her feelings about boys will subside within the next year. 4. They should have their daughter speak with the school counselor.

2. Her behavior is common among school age children.

Davis: It is discovered that a pregnant woman practices pica. Which of the following complications is most often associated with this behavior? 1. Hypothyroidism. 2. Iron-deficiency anemia. 3. Hypercalcemia. 4. Overexposure to zinc.

2. Iron-Deficiency anemia.

It is discovered that a pregnant woman practices pica. which of the following complications is most often associated with this behavior? 1. Hypothyroidism 2. Iron-deficiency anemia 3. Hypercalcemia 4. Overexposure to zinc.

2. Iron-deficiency anemia

ATI: A nurse is assessing an infant who has scabies. Which of the following are expected findings. Select all that apply. 1. Presence of nits on the hair shaft. 2. Pencil-like marks on hands. 3. Blisters on the soles of the feet. 4. Bluish-gray skin color. 5. Pimples on the trunk

2. Pencil-like marks on hands. 3. Blisters on the soles of the feet. 5. Pimples on the trunk

Davis: Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? Select all that apply. 1. +3 pitting edema. 2. Petechiae. 3. Jaundice. 4. +4 deep tendon reflexes. 5. Elevated specific gravity.

2. Petechiae. 3. Jaundice.

Davis: A lecithin:sphingomyelin (L/S) ratio has been ordered by a pregnant woman's obstetrician. Which of the following data will the nurse learn from this test? 1. Coagulability of maternal blood. 2. Maturation of the fetal lungs. 3. Potential for fetal development of erythroblastosis fetalis. 4. Potential for maternal development of gestational diabetes

2. Maturation of the fetal lungs.

Davis: A 30-year-old gravida, G3P1101, 6 weeks' gestation, states that her premature baby boy, born 8 years ago, died shortly after delivery from an infection secondary to spina bifida. Which of the following interventions is most important for this client? 1. Grief counseling. 2. Nutrition counseling. 3. Infection control counseling. 4. Genetic counselin

2. Nutrition counseling.

Davis: A client is being admitted to the labor suite with a diagnosis of eclampsia. Which of the following actions by the nurse is appropriate at this time? 1. Tape a tongue blade to the head of the bed. 2. Pad the side rails and head of the bed. 3. Provide the client with needed stimulation. 4. Provide the client with grief counseling.

2. Pad the side rails and head of the bed.

Davis: A 29-week-gestation woman diagnosed with severe preeclampsia is noted to have blood pressure of 170/112, 4 proteinuria, and a weight gain of 10 pounds over the last 2 days. Which of the following signs/symptoms would the nurse also expect to see? 1. Fundal height of 32 cm. 2. Papilledema. 3. Patellar reflexes of 2. 4. Nystagmus.

2. Papilledema.

Which activity can the nurse provide for a 9 year old to encourage a sense of industry? 1. Allow the child to choose what time to take his medications. 2. Provide the child with the homework his teacher has sent. 3. Allow the child to assist with his bath. 4. Allow the child to help with his dressing change.

2. Provide the child with the homework his teacher has sent.

Davis: A gravid client is admitted with a diagnosis of third-trimester bleeding. The nurse must carefully monitor for a change in which of the following vital signs? 1. Temperature. 2. Pulse. 3. Respirations. 4. Blood pressure.

2. Pulse.

ATI: A nurse is caring for an adolescent whos mother expresses concerns about her son sleeping such long hours. The nurse should inform the mother that additional sleep is needed during adolescence due to which of the following? 1. Sleep terrors. 2. Rapid growth. 3. Elevated zinc levels. 4. Slowed metabolism.

2. Rapid Growth

Davis: A client, G8P3406, 14 weeks' gestation, is being seen in the prenatal clinic. During the nurse's prenatal teaching session, the nurse will emphasize that the woman should notify the obstetric office immediately if she notes which of the following? 1. Change in fetal movement. 2. Signs and symptoms of labor. 3. Swelling of feet and ankles. 4. Appearance of spider veins.

2. Signs and symptoms of labor.

A woman tells the nurse that she would like suggestions for alternate vitamin C sources because she isn't very fond of citrus fruit. Which of the following suggestions is appropriate? 1. Barley and brown rice. 2. Strawberries and potatoes. 3. Buckwheat and lentils. 4. Wheat flour and figs.

2. Strawberries and potatoes.

Davis: A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appropriate action for the nurse to perform next? 1. Inquire whether or not the client has allergies. 2. Take the woman's blood pressure. 3. Assess the woman's fundal height. 4. Ask the woman about stressors at work.

2. Take the woman's blood pressure.

Davis: At 28 weeks' gestation, an Rh-negative woman receives RhoGAM. Which of the following would indicate that the medication is effective? 1. The baby's Rh status changes to Rh negative. 2. The mother produces no Rh antibodies. 3. The baby produces no Rh antibodies. 4. The mother's Rh status changes to Rh positive.

2. The mother produces no Rh antibodies.

An 18 year old with a rash and itching in the groin area is concerned that he has contracted a STD and does not want his parents to find out. The nurses best response is: 1. We will need to contact your parents to let them know. 2. We will not contact your parents regarding this visit. 3. Who would you like us to contact about your visit here today? 4. We cannot promise that the hospital will not contact your parents.

2. We will not contact your parents regarding this visit.

ATI: A nurse is teaching a course about safety during the school age years to a group of parents. Which of the following information should the nurse include in the course? Select all that apply. 1. Gaiting stairs at the top and bottom. 2. Wearing helmets when riding bicycles or skateboarding. 3. Riding safely in bed of pickup trucks. 4. Implementing firearm safety. 5. Wearing seat belts.

2. Wearing helmets when riding bicycles or skateboarding. 4. Implementing firearm safety. 5. Wearing seat belts.

Davis: A client's 32-week clinic assessment was: BP 90/60; TPR 98.6ºF, P 92, R 20; weight 145 lb; and urine negative for protein. Which of the following findings at the 34-week appointment should the nurse highlight for the certified nurse midwife? 1. BP 110/70; TPR 99.2ºF, 88, 20. 2. Weight 155 lb; urine protein 2. 3. Urine protein trace; BP 88/56. 4. Weight 147 lb; TPR 99.0ºF, 76, 18.

2. Weight 155 lb; urine protein 2.

ATI: A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the clients laboratory reports. Which of the following findings is a clinical manifestation of this condition. 1. Hgb 12.2 g/dL 2. Urine ketones present 3. Alanine aminiotransferase 20 IU/L 4. Serum glucose 114 mg/dL

2. Urine ketones present.

Davis: The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal? 1. +1. 2. +2. 3. +3. 4. +4.

3. +3

Davis: The nurse has assessed four primigravid clients in the prenatal clinic. Which of the women would the nurse refer to the nurse midwife for further assessment? 1. 10 weeks' gestation, complains of fatigue with nausea and vomiting. 2. 26 weeks' gestation, complains of ankle edema and chloasma. 3. 32 weeks' gestation, complains of epigastric pain and facial edema. 4. 37 weeks' gestation, complains of bleeding gums and urinary frequency.

3. 32 weeks' gestation, complains of epigastric pain and facial edema.

Davis: Which of the following findings should the nurse expect when assessing a client, 8 weeks' gestation, with gestational trophoblastic disease (hydatiform mole)? 1. Protracted pain. 2. Variable fetal heart decelerations. 3. Dark brown vaginal bleeding. 4. Suicidal ideations.

3. Dark brown vaginal bleeding.

Davis: A woman is recovering at the gynecologist's office following a late first-trimester spontaneous abortion. At this time, it is essential for the nurse to check which of the following? 1. Maternal rubella titer. 2. Past obstetric history. 3. Maternal blood type. 4. Cervical patency.

3. Maternal blood type.

ATI: A nurse is discussing prepubescence and preadolescence with a group of parents of school age children. Which of the following information should the nurse include in the discussion? 1. Initial physiologic changes appear during early childhood. 2. Changes in height and weight occur slowly during this period. 3. Growth differences between boys and girls become evident. 4. Signs of sexual maturation become highly visible in boys.

3. Growth differences between boys and girls become evident.

During an adolescents initial physical assessment, the nurse notes signs and symptoms of nutritional deficit. Which assessment let the nurse to this initial conclusion? 1. Protein level WNL 2. Blood pressure is 110/66 3. Hair and nails are brittle and dry. 4. Teeth appear to be eroded

3. Hair and nails are brittle and dry

ATI: A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea and comiting and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect. 1. Hyperemesis gravidarum. 2. Threatened abortion. 3. Hydatidiform Mole 4. Preterm Labor

3. Hydatidiform Mole

The mother of a 13 year old girl tells the nurse that she is concerned because her daughter has gained 10 lbs since she began puberty. The childs mother asks the nurse for advice about what to do about her daughters weight gain. Which should the nurse do? 1. Provide the childs mother with some pamphlets on nutrition and healthy eating. 2. Provide the childs mother with information about new exercise programs for teens. 3. Inform the childs mother that it is common for teen girls to gain weight during puberty. 4. Inform the childs mother that her daughter will likely gain another 5 to 10 lbs in the next year.

3. Inform the childs mother that it is common for teen girls to gain weight during puberty.

The mother of 11 year old fraternal twins tells the nurse at their well child checkup that she is concerned because her daughter has gained more weight and height than her twin brother. The mother is concerned that there is something wrong with her son. The nurse's best response is: 1. I understand your concern. I will talk with the physician, and we can draw some lab work. 2. Let me ask you whether your son has been ill lately. 3. It is normal for girls to grow a little taller and gain more wight than boys at this age. 4. It is normal for you to be concerned, but I am sure your son will catch up with your daughter eventually.

3. It is normal for girls to grow a little taller and gain more wight than boys at this age.

Davis: When assessing the fruit intake of a pregnant client, the nurse notes that the client usually eats 1 piece of fruit per day and drinks a 12 oz glass of fruit juice per day. Which of the following is the most important communication for the nurse to make? 1. You are effectively meeting your daily fruit requirements. 2. Fruit juices are excellent sources of folic acid. 3. It would be even better if you were to consume more whole fruits and less fruit juice. 4. Your fruit intake far exceeds the recommended daily fruit intake.

3. It would be even better if you were to consume more whole fruits and less fruit juice.

When assessing the fruit intake of a pregnant client, the nurse notes that the client usually eats 1 piece of whole fruit per day and drinks a 12 oz glass of fruit juice per day. Which of the following is the most important communication for the nurse to make? 1. You are effectively meeting your daily fruit requirements. 2. Fruit juices are excellent sources of folic acid. 3. It would be even better if you were to consume more whole fruits and less fruit juice. 4. Your fruit intake far exceeds the recommended daily fruit intake.

3. It would be even better if you were to consume more whole fruits and less fruit juice.

An adolescent has a diagnosis of new onset diabetes. What would most influence a teenagers food choices as he begins to make changes in his diet? 1. Parents and their dietary choices. 2. Cultural background. 3. Peers and their dietary choices. 4. Television and other forms of media influence.

3. Peers and their dietary choices.

Davis: Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.

3. Platelets 75,000.

Which is the best method of distraction for an 8 year old who is having surgery later today and is NPO? 1. Use the telephone to call friends. 2. Watch TV 3. Play a board game 4. Read the central line pamphlet he was given.

3. Play a board game

Davis: A client with mild preeclampsia, who has been advised to be on bed rest at home, asks why it is necessary. Which of the following is the best response for the nurse to give the client? 1. "Bed rest will help you to conserve energy for your labor." 2. "Bed rest will help to relieve your nausea and anorexia." 3. "Reclining will increase the amount of oxygen that your baby gets." 4. "The position change will prevent the placenta from separating."

3. Reclining will increase the amount of oxygen that your baby gets.

Which technique should the nurse suggest to the mother of an 8 year old who does not want to complete her chores? 1. Grounding 2. Time-out 3. Reward System 4. Spanking

3. Reward System

Davis: A woman has been diagnosed with a ruptured ectopic pregnancy. Which of the following signs/symptoms is characteristic of this diagnosis? 1. Dark brown rectal bleeding. 2. Severe nausea and vomiting. 3. Sharp unilateral pain. 4. Marked hyperthermia.

3. Sharp unilateral pain.

The mother of a 15 year old is frustrated because he spends much of his weekend time sleeping. Which is the nurses best response to the mother's frustration? 1. Your son may be trying to catch up on the sleep missed during the week. 2. Developmental theorists believe that teens require more sleep as they begin to integrate new roles into their lives. 3. Teen require more sleep due to the rapid physical growth that is occurring. 4. Teens require more sleep due to the increase in their social obligations.

3. Teen require more sleep due to the rapid physical growth that is occurring.

ATI: A nurse is teaching a class about puberty in males. Which of the following should the nurse include as the first manifestation of sexual maturation? 1. Pubic hair growth. 2. Vocal changes. 3. Testicular enlargement. 4. Facial hair growth.

3. Testicular enlargement.

Which statement would indicate to the nurse that a school-age child is not developmentally on track for age? 1. The child is able to follow a four to five step command 2. The child started wetting the bed on admission to the hospital. 3. The child has an imaginary friend named Kelly. 4. The child enjoys playing board games with her sister.

3. The child has an imaginary friend named Kelly.

Davis: Which of the following would indicate that a nipple stimulation test is creating the desired effect? 1. The woman's inverted nipples become erect. 2. The woman's nipple and breast tissue hypertrophy. 3. The woman's uterus contracts 3 times in 10 minutes. 4. The woman's cervix dilates 2 centimeters in 3 hours.

3. The woman's uterus contracts 3 times in 10 minutes.

A 13 year old tells the nurse that he is worried because his breasts are growing. They hurt, and he is embarrassed to take his shirt off during gym class. What should the nurse tell him? 1. The pediatrician will draw some blood to find out why your breasts are growing. 2. It is just a slight hormonal imbalance that can be easily corrected with medication. 3. This is a normal condition of puberty that will resolve within a year or two. 4. This is a rare finding that occurs in about 5% of boys during puberty.

3. This is a normal condition of puberty that will resolve within a year or two.

Davis: A gravid woman, who is 42 weeks' gestation, has just had a 20-minute nonstress test (NST). Which of the following results would the nurse interpret as a reactive test? 1. Moderate fetal heart baseline variability. 2. Maternal heart rate accelerations to 140 bpm lasting at least 20 seconds. 3. Two fetal heart accelerations of 15 bpm lasting at least 15 seconds. 4. Absence of maternal premature ventricular contractions.

3. Two fetal heart accelerations of 15 bpm lasting at least 15 seconds.

ATI: A nurse is teaching a parent of a child who has pediculosis capitis. Which of the following should the nurse include in the teaching? 1. Apply mayonnaise to the affected area at night. 2. Treat all household pets. 3. Use an over the counter medication containing 1% permitherin 4. Discard the child''s stuffed animals.

3. Use an over the counter medication containing 1% permitherin.

Davis: A woman is to receive RhoGAM at 28 weeks' gestation. What action must the nurse take before giving the injection? 1. Validate that the baby is Rh negative. 2. Assess that the direct Coombs' test is positive. 3. Verify the identity of the woman. 4. Reconstitute the globulin with sterile water.

3. Verify the identity of the woman.

Davis: A nurse is caring for a 25-year-old client who has just had a spontaneous first trimester abortion. Which of the following comments by the nurse is appropriate? 1. "You can try again very soon." 2. "It is probably better this way." 3. "At least you weren't very far along." 4. "I'm here to talk if you would like."

4. "I'm here to talk if you would like."

Davis: A client has just been diagnosed with gestation diabetes. She cries, "Oh no! I will never be able to give myself shots!!" Which of the following responses by the nurse is appropriate at this time? 1. "I am sure you can learn for your baby." 2. "I will work with you until you feel comfortable giving yourself the insulin." 3. "We will be giving you pills for the diabetes." 4. "If you follow your diet and exercise you will probably need no insulin."

4. "If you follow your diet and exercise you will probably need no insulin."

ATI: A nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency? 1. Iron deficiency anemia 2. Poor bone formation 3. Macrosomic fetus 4. Neural tube defects

4. Neural Tube defects

What information should a school nurse include in a discussion on nutrition with a fourth grade class? 1. The number of calories that a fourth grade child should consume in a day. 2. A list of high calorie foods that all fourth graders should avoid. 3. How to read food labels so children know which foods are good for them. 4. A list of nutritious foods with basic scientific information about how they affect the body organs and systems.

4. A list of nutritious foods with basic scientific information about how they affect the body organs and systems.

ATI: A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? 1. Nifedipine 2. Pyridoxine 3. Ferrous Sulfate 4. Calcium gluconate

4. Calcium gluconate

ATI: A nurse is caring for a client in active labor. When last examined 2 hours ago, the clients cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states my water broke. the monitor reveals a HFR of 80-85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the clients vagina. Which of the following actions should the nurse perform first? 1. Place the client in the trendelenburg position. 2. Apply pressure to the presenting part with her fingers. 3. Administer oxygen at 10 L/min via a face mask. 4. Call for assistance.

4. Call for assistance.

A patient informs the nurse that she is very constipated. Which of the following foods would be best for the nurse to recommend to the client? 1. Pasta. 2. Rice. 3. Yogurt. 4. Celery.

4. Celery.

Davis: A client informs the nurse that she is very constipated. Which of the following foods would be best for the nurse to recommend to the client? 1. Pasta. 2. Rice. 3. Yogurt. 4. Celery.

4. Celery.

Davis: A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output 30 cc/hr. 3. Respiratory rate 16 rpm. 4. Client has no grand mal seizures.

4. Client has no grand mal seizures.

Davis: During a prenatal interview, a client tells the nurse, my mother told me she had toxemia during her pregnancy and almost died. Which of the following questions should the nurse ask in response to this statement. 1. Does your mother have a cardiac condition? 2. Did your mother tell you what she was toxic from? 3. Does your mother have diabetes now? 4. Did your mother say whether she had a seizure or not?

4. Did your mother say whether she had a seizure or not?

Davis: A 25-year-old client is admitted with the following history: 12 weeks pregnant, vaginal bleeding, no fetal heart beat seen on ultrasound. The nurse would expect the doctor to write an order to prepare the client for which of the following? 1. Cervical cerclage. 2. Amniocentesis. 3. Nonstress testing. 4. Dilation and curettage

4. Dilation and curettage

Davis: A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools. 4. Epigastric pain.

4. Epigastric Pain.

ATI: A nurse is providing education about sleep and rest to a group of parents of school age children. Which of the following statements by a parent indicates a need for further teaching? 1. My childs age influences the number of hours of sleep he needs. 2. My childs level of activity during the day influences the number of hours of sleep he needs. 3. My childs health status influences the number of hours of sleep he needs. 4. My childs family history of sleep apnea influences the number of hours of sleep he needs.

4. My childs family history of sleep apnea influences the number of hours of sleep he needs.

Which statement accurately describes how the nurse should approach an 11 year old to do a physical assessment? 1. Ask the child's parents to remain in the room during the physical exam. 2. Auscultate the heart, lungs, and abdomen first. 3. Explain that the physical exam will not hurt. 4. Explain what the nurse will be doing in basic understandable terms.

4. Explain what the nurse will be doing in basic understandable terms.

Davis: A client has severe preeclampsia. The nurse would expect the primary health care practitioner to order tests to assess the fetus for which of the following? 1. Severe anemia. 2. Hypoprothrombinemia. 3. Craniosynostosis. 4. Intrauterine growth restriction

4. Intrauterine growth restriction.

ATI: A nurse is reviewing a new prescription for iron supplements with a client who is in the 8th week of gestation and has iron deficiency anemia. The nurse should advise the client to take the iron supplements with which of the following? 1. Ice water. 2. Low fat or whole milk. 3. Tea or coffee. 4. Orange Juice.

4. Orange Juice.

A nurse has identified the following nursing diagnosis for a prenatal client: altered nutrition: less than body requirements related to poor folic acid intake. Which of the following foods should the nurse suggest the client consume? 1. Potatoes and grapes 2. Cranberries and squash 3. Apples and corn 4. Oranges and spinach

4. Oranges and spinach

Davis: The nurse is caring for a client who was just admitted to the hospital to rule out ectopic pregnancy. Which of the following orders is the most important for the nurse to perform? 1. Assess the client's temperature. 2. Document the time of the client's last meal. 3. Obtain urine for urinalysis and culture. 4. Report complaints of dizziness or weakness.

4. Report complaints of dizziness or weakness.

ATI: A nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the following is an expected finding? 1. No alteration in menses. 2. Transvaginal ultrasound indicating a fetus in the uterus. 3. Serum progesterone greater than the expected reference range. 4. Report of severe shoulder pain.

4. Report of severe shoulder pain.

Davis: A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of 3. 2. Urinary output of 30 cc/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 gm/dL.

4. Serum magnesium level of 9 gm/dL.

The mother of an adolescent complains that he has had some recent behavioral changes. He comes home from school every day, closes his door, and refrains from interaction with his family. The nurses best response to the mother is: 1. You should speak with your son and ask him directly what is wrong with him. 2. you should set limits with your son and tell him that this is unacceptable behavior. 3. Your sons behavior is abnormal, and he is going to need a psychiatric referral. 4. Your sons behavior is normal. you should listen to him without being judgmental.

4. Your sons behavior is normal. you should listen to him without being judgmental.

A woman asks the nurse about consuming herbal supplements during pregnancy. Which of the following responses is appropriate? 1. Herbals are natural substances, so they are safely ingested during pregnancy. 2. It is safe to take licorice and cat's claw, but no other herbs are safe. 3. A federal commission has established the safety of herbals during pregnancy. 4. The woman should discuss everything she eats with a health care practitioner.

4. The woman should discuss everything she eats with a health care practitioner.