PRIORITY OB/PEDS Hesi
A 17-year-old male student with cystic fibrosis talks with the school nurse about his disease and wonders how it will affect getting married and having children. Which relevant information would the nurse include in this discussion?
He is likely to have infertility problems and needs further evaluation
A new infant is receiving positive pressure ventilation after delivery. Based on which assessment finding should the nurse initiate chest compressions?
Heart rate 54
The nurse if caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus if firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
Heart rate and blood pressure
The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using a Medela Haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instruction should the nurse provide the mother about feedings?
Hold the newborn in an upright position.
One week after missing her menstrual period, a woman performs an OTC pregnancy test and it is positive. Which hormone is responsible for producing the positive result?
Human chorionic gonadotrophin
A 5-year-old boy is diagnosed with diabetes mellitus Type 1. Which stage of Erikson's theory of psychosocial development is the nurse addressing when teaching this client about insulin injections?
Industry
At 0600 while admitting a woman for a scheduled repeat c section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. What action should the nurse take first?
Inform the anesthesia care provider
Following the vaginal delivery of a large for gestation age (LGA) infant, a woman is admitted to the ICU due to post-partum hemorrhaging. The client's medical record describes Jehovah's Witness notes as her religion. What action should the nurse take next?
Inform the client of the critical need for a blood transfusion
A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to sickle cell crisis. Which intervention should the nurse implement first?
Initiate normal saline IV at 50 mL/hr.
The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.)
-Admission weight of 4 pounds, 15 ounces (2244 grams) -Head to heel length of 17 inches (42.5 cm). -Frontal occipital circumference of 12.5 inches (31.25 cm).
To maintain patency of the ductus arteriosus, the nurse administers a prescribed dose of prostaglandin IV to a week old infant diagnosed with transposition of the greta vessels. Based on which assessment finding should the nurse stop the medication administration immediately?
Blood pressure of 80/50
The mother of an infant born with hypospadias is concerned because she has been told that her child cannot be circumcised according to her Jewish faith tradition. Which response is best for the nurse to provide?
"During the surgery part of the foreskin is used to repair the meatus."
A 4-year-old girl returns to the pediatrician's office for a postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should the nurse consider normal for this age child?
"Talks" to an imaginary friend
The nurse is discussing involution with a post-partum client. Which statement best indicates that the client understands the effect of breastfeeding on the resumption of menstrual cycle?
"While I am breastfeeding, my period may be delayed"
The mother of a 6-year-old girl is concerned about her child's obesity. The child's weight plots at the 75 percentile, and height at the 25 percentile. The child's body mass index (BMI) is at the 85 percentile for age and gender. Which intervention should the nurse implement? (Select all that apply)
-Determine the child's usual physical activity pattern -Obtain the child's 3-day diet history based on the mother's input -Inquire as to whether or not the school has a physical education program
The nurse is caring for a newborn infant who was recently diagnosed with congenital heart defect. Which assessment finding warrants immediate intervention by the nurse?
Bluish tinge to the tongue
A multigravida client in labor is receiving oxytocin Pitocin 4mu/minute to help promote an effective contraction pattern. The available solution is Lactated Ringers 1,000 ml with Pitocin 20 units. The nurse should program the infusion pump to deliver how many ml/hr?
12 mL
The nurse administers digoxin to a 9-month-old infant with an apical heart rate of 150 beats per minute. Which apical pulse rate indicates that the therapeutic effect of the mediation has been achieved?
120 beats per minute
The nurse is administering a secondary infusion of amilacin 600 mg IV in 100 mL of D5W over 45 minutes every 8 hours for a child who weighs 40 kg. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number)
133
The healthcare provider prescribes Cephalexin 350 mg by mouth every 6 hours for a child who weighs 88 pounds. The available suspension is labeled, "Cephalexin Suspension 125 mg/5 mL." The recommended safe dose range is 25 to 50 mg/kg/24 hours in 4 divided doses. How many milliliters should the nurse administer based on the child's weight? (enter numerical value only. If rounding is required, round to the nearest whole number).
14
A 32- week primigravida who is in preterm labor receives a prescription for an infusion of D5W 500 ml with magnesium sulfate 20 grams at 1 gram/hour. How many ml/hour should the nurse program the infusion pump?
25 mL
A clinic nurse is assessing infants and toddlers for fine and gross motor development. Which child should the nurse refer to a healthcare provider for further evaluation?
3-year-old preferring to walk on the tip toes.
Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first?
A 39-week primigravida with biophysical profile score of 5 out of 8.
The nurse in the Emergency Center is training an 8-year-old boy who fell from a tree. The child is crying and complaining of pain in the left forearm. Which intervention should the nurse implement first?
Apply a cold pack to his left forearm
The nurse is planning care for a 4-year-old girl who is diagnosed as having developmental disability. Which should be the primary focus of treatment for this child?
Assist in preventing further disability
An infant is admitted for surgery who has a Wilms' tumor. Which nursing intervention should the nurse implement during the preoperative period?
Careful bathing and handling that avoids abdominal manipulation
Which nursing intervention is most important to assist in detecting hypopituitarism and hyperpituitarism in children?
Carefully recording the height and weight of children to detect inappropriate growth rates
While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heartrate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the nurse take first?
Change the maternal position
A 6-year-old child is brought into the healthcare provider's office after stepping on a rusty nail. Upon inspection, the nurse notes that the nails went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?
Cleanse the foot with soap and water and apply an antibiotic ointment as prescribed
A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to patient's safety, which short-term goal should the nurse include in the plan of care?
Consumes 3 meals and 1500 mL of fluid per day
A new mother, who is lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge?
Continue prenatal vitamins with B12 while breast feeding
The nurse is assessing a 38- week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extra-uterine life?
Cries vigorously when stimulated
The nurse plans to screen only the highest risk children for scoliosis. Which group of children should the nurse screen first?
Girls between ages 10 and 114
A 6-month-old, diagnosed with short bowel syndrome, began enteral feedings yesterday. To maintain normal growth and development of the child during this period, what action should the nurse include in the infant's plan of care?
Give the infant a pacifier during feedings
The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops) followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?
Give the mother positive feedback about the way she administered the medication
A 3 hour old male infant's hands are feet are cyanotic, and he has an axillary temperature of 96.5 F, a respiratory rate of 40 breaths/min, and a heart rate of 165 beats/min. Which nursing intervention is best for the nurse to implement?
Gradually warm the infant under a radiant heat source
Which nursing problem has the highest priority when providing preoperative care for an infant born with bladder exstrophy?
Risk for infection related to impaired skin integrity
Then ruse is caring for a child newly diagnosed with attention deficit hyperactive disorder (ADHD). The child's mother asks about information of the treatment options. Which information is most helpful for the nurse to provide?
Explore the combination of medication and behavioral therapies
One hour after delivery, the nurse is unable to palpate the uterine fundus of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should the nurse implement next?
Palpate the suprapubic area for bladder distention
The health care provider hands a newborn to the nurse after a vaginal delivery. What action is most important for the nurse to implement?
Place the infant under a warming unit
The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of 8 pounds at 36- weeks gestation. This amniocentesis is being performed to obtain which information?
Fetal lung maturity
On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?
Filling and secreting colostrum
A nurse is caring for a client following an emergency cesarian delivery under general anesthesia. Which assessment finding, occurring in the first 8 hours after delivery, is most critical and requires immediate intervention?
uterine atony
A 16-year-old adolescent with acute myelocyte leukemia is receiving chemotherapy via an implanted medication port at the outpatient oncology clinic. What action should the nurse implement when the infusion is complete?
Flush the mediport with saline and a heparin solution
Which nutritional information should the nurse plan to provide the mother of a 6-month-old regarding introduction of solid foods?
Food should be introduced into a child's diet one at a time, at 4 to 7 day intervals
At 0600 while admitting a woman for a scheduled repeat cesarean section. The client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid a headache. Which action should the nurse take first?
Inform anesthesia care provider
A new mother who is breastfeeding her 4-week-old infant & has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
Inform her that a decreased need for insulin occurs while breastfeeding
The nurse is counseling a client who is at 6 weeks gestation and is experiencing morning sickness but does not want to take any drugs for this discomfort. Which herbal supplement is likely to help this client with the nausea she is experiencing?
Ginger
A three-hour old infant's hands and feet are cyanotic, and he has an axillary temperature of 96.5 F, a respiratory rate of 40 bpm, and the heart rate of 165 beats per minute. Which nursing intervention is best for the nurse to implement?
Gradually warm the infant under a radiant heat source
The newborn nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a newborn's admission. What action should the nurse take to ensure adequate instillation of the ophthalmic ointment?
Instill a thin ribbon into each lower conjunctival sac
The nurse is conducting discharge teaching with the mother of a 22-month-old with respiratory syncytial virus (RSV) who has one younger and one old sibling living in the home. Which priority instruction should the nurse include in this teaching plan?
Institute airborne precautions for the infected child
A client in labor states, "I think my water just broke!" the nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?
Place the client in Trendelenburg
A client at 40-weeks' gestation is admitted to labor and delivery. Her obstetrical history includes three life births at 39, 38, and 35-weeks' gestation, 2 miscarriages at 6 & 8-weeks' gestation, and a fetal demise at 33-weeks gestation. Which is an accurate summary of this client's obstetrical history?
Gravida 6 Term 3 Preterm 1 Abortion 2 Living 3
A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first?
Place the infant on the abdomen to protect the sac
Two days after delivery, a postpartum mother receives the rubella vaccine before being discharged home. Which statement by the mother indicates she understands her discharge teaching about the vaccine?
I should not get pregnant for one month after receiving the rubella vaccine
A client who suspects she is pregnant tells the nurse she has a peptic ulcer and is being treated with misoprostol, a synthetic prostaglandin E drug. How should the nurse respond?
"You may be at higher risk for having a spontaneous miscarriage"
A laboring client with gestational diabetes is receiving an IV infusion with regular insulin at 5 units/hour. The IV solution contains 100 units of regular insulin in 250 mL of 0.9% normal saline. The nurse should program the infusion pump to deliver how many mL/hour?
13
The nurse is planning to administer betamethasone to a gravid client. Which client is most likely to receive this prescription?
30-weeks' gestation who is contracting regularly and exhibiting cervical change
A primigravida client receives a prescription for an infusion of oxytocin at 12 millunits/minute. The available solution is Ringer's Lactate 1,000 mL with oxytocin 10 units. The nurse should program the infusion pump to deliver how many mL/hour?
7200
In determining the one minute Apgar score of a male infant, the nurses assesses a heart rate of 120 bpm and 44 respirations/min. He has a loud cry with stimulation, good muscle tone, and his color is acrocyanotic. What Apgar score should the nurse assigned?
9
A father of a 3-day-old infant who is breast feeding calls the postpartum......
A fluctuation of hormones in the early postpartum period can cause mood changes
Which content should the nurse plan to include in a nutrition class for a pregnant adolescent?
A. Take folic acid supplements daily B. Take iron & calcium supplements daily C. Maintain current protein intake
A client at 38-weeks' gestation complains of severe abdominal pain. Upon palpation, the nurse notes that the abdomen is rigid. How should the nurse document the findings?
Abruptio placenta
A client at 38-weeks gestation presents to the labor and delivery unit in active labor. Based on which assessment finding should the nurse notify the surgery team to prepare for a primary cesarean section?
Active herpes lesions on the perineum
A client who is 3 weeks postpartum tells a nurse "I am so tired all the time I didn't know having a baby would be so hard".Which response should the nurse provide?
Adjusting to a new baby can be difficult. Tell me more about any help you are receiving
The current vital signs for a primipara who delivered vaginally during the previous shift are: Temp 100.4, heart rate 58 bpm, respiration 16 bpm, and BP 130/74. What action should the nurse implement?
Document the vital signs in the record
A full-term infant is admitted to the newborn nursery 2 hours after delivery. The delivery record indicates the mother is positive for HIV and receiving Zidovudine intravenously during labor. which action should the nurse implement?
Ensure that Zidovudine given within six hours after birth
What should be the primary focus of nursing care in the transitional face of labor for a client who anticipates an unmedicated delivery?
Assessing the strength of uterine contractions
A nurse is preparing to administer methylergonovine maleate to a postpartum client. Based on which assessment finding should the nurse withhold the drug?
Blood pressure 149/90
A gravid client is living alone in an apartment wishes to purchase a pet. Which choice should the nurse instruct this client to avoid?
Cat
A client at 35 weeks gestation complains of a "pain whenever the baby moves". On assessment, the nurse notes the client's temperature to be 101.2 F, with severe abdominal or uterine tenderness on palpitation. The nurse knows that these findings are indicative of which condition?
Chorioamnionitis
A client who is 37 weeks gestation comes to the woman's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure which action should the nurse implement next?
Collect urine sample to screen for protein
The father of a 3- day- old infant who is breast feeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cried for no apparent reason. What information is most important for the nurse to provide to this father?
Contact the clinic if the behaviors continue for more than two weeks or become worse
The nurse is assessing a 38-week gestation newborn infant immediately following a vagina birth. Which assessment finding indicates that the infant is transitioning well too extrauterine life?
Cries vigorously when stimulated
A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings f the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?
Determine current cervical dilation
A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the client's record indicates that she was medicated 30 minutes ago with butorphanol tartare 2 mg & promethazine 25 mg IV push. Vaginal examination reveals that the client's cervical dilation is 3 cm, 70% effaced, and at a 0 station. Which action should the nurse implement?
Instruct the client to use deep breathing during a contraction
A one-day-old neonate develops a cephaihematoma. The nurse should closely assess this neonate for which common complication?
Jaundice
Following a precipitous labor, a postpartum client has a continuous trickling of bright red blood from her vagina. Her uterus is firm, and her vital signs are within normal limits. The nurse determines at that sign may indicate which condition?
Laceration on the cervix
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
Maternal blood pressure
A woman who delivered a normal newborn 24 hours ago complains, " I seem to be urinarting every hour or so. Is that ok?". Which action should the nurse implement?
Measure the next voiding, then palpate the clients bladder
The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
Obtain a drug screen for cocaine
The parents of a male newborn have signed an informed consent for circumcision. What priority intervention should the nurse implement upon completion of the circumcision?
Place petrolatum gauze dressings on the site
A multiparous woman at 38-weeks gestation with a history of rapid progression of labor is admitted for induction due to signs & symptoms of preeclampsia. One hour after an oxytocin infusion is initiated, she reports a headache. For the past 30 minutes her contractions are occurring every 1 to 2 minutes, lasting 60 to 75 seconds, and a vaginal exam indicates that her cervix is 90% effaced & dilated to 6 cm. Which intervention is most important for the nurse to implement?
Prepare for immediate delivery
Following a vaginal delivery, the nurse places the neonate under the radiant warmer, provides naso-oropharyneal suction, and dries the neonate's skin to elicit spontaneous respirations. The newborn's heart rate is 100 beats/minute & remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?
Provide positive pressure ventilation
The nurse receives change-of-shift report for four newborns. The nurse should monitor closely which newborn for an increased risk for developing neonatal sepsis
Reported prolonged rupture of membranes
The nurse performs a routine assessment on a 12-hour-old infant. Which finding requires intervention?
Respiratory rate of 73 breaths/minute
A pregnant client receives Rho(D) immune globin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8 F. Which action should the nurse implement?
Schedule a visit with the healthcare provider today
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone is there anything else I can do to make sure my baby is healthy?". Which information should the nurse provide?
Start a prenatal care plan as soon as possible
When preparing to assist the healthcare provider with a vaginal examination to assess a client's cervical dilation during labor, which equipment should the nurse assemble?
Sterile glove & lubricant
A primigravida client asks the nurse about exercising during pregnancy to prepare for labor. Which recommendation should the nurse provide?
Stretching exercises are good preparation for labor
A pregnant client mentions her history that she changes a cat's litter box daily. Which test should the nurse anticipate the healthcare provider to prescribe?
TORCH screening
During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage?
Test the fluid with a nitrazine strip
Vaginal prostaglandin gel is used to induce labor for a woman who is at 42 weeks gestation. Thirty minutes after insertion of the gel, the client complains of vaginal warmth, and is experiencing 90 second contractions with fetal heart rate decelerations. What action should the nurse implement first?
Turn to a side-lying position
The nurse is assessing a pregnant client who reports that she smokes one pack of cigarettes per day. The client believes she is six months pregnant but is unsure of the date of her last menstrual period. Which method of assessment provides the best estimate of gestational age?
Ultrasonography
The nurse is preparing to draw blood from a newborn to obtain hemoglobin & hematocrit levels. What is the best method to obtain this blood sample?
Use a lancet to puncture the outer lateral aspect of the heel
The nurse is preparing to draw blood from a newborn to obtain hemoglobin and hematocrit levels. What is the best method to obtain this blood sample?
Use a lancet to puncture the outer lateral aspect of the heel
A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide the client?
When there is no significant vagina bleeding
Following an amniocentesis, which nursing intervention has the highest priority?
assess the insertion site
The nurse is assessing a postpartum client who delivered a 10 pounds infant vaginally 2 hours ago. The client's fundus is 2 fingerbreadths above the umbilicus, deviated to the right side, and boggy. After the client voids 250 mL of urine using a bedpan, which option should the nurse implement?
assist the client to the bathroom to void
A 17-year-old client gave birth 12 hours ago. She states that she doesn't know how to care for her baby. To promote parent-infant attachment behaviors, which intervention should the nurse implement?
encourage rooming in while in the hospital
A client at 30 weeks gestation report says she has not felt the baby move in the last 24 hours, concerned she arrives in panic at the obstetric clinic where she is immediately sent to the hospital. Which assessment finding warrants immediate intervention by the nurse?
fetal heart rate 60 bpm
When planning care for the newborn of an insulin-dependent diabetic mother, the nurse should be alert for which condition that should be reported immediately to the health care provider
hypoglycemia at birth
Following the vaginal delivery of an LGA infant, a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client's medical record list the client's religion as Jehovah witness which action should the nurse take?
inform the client of the critical need for a blood transfusion
A primipara client at 42-weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion her cervix is 100% effaced & 5 cm dilated, contractions are occurring every 1 minute with a 75 second duration. The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with a 20 second duration. Which intervention should the nurse implement?
restart oxytocin infusion rate per protocol
A diabetic client delivers a full term large for gestational age infant who is jittery. What action should the nurse take first?
Obtain a blood glucose level
The nurse is assessing a newborn who was precipitously delivered at 38 weeks gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
Obtain a drug screen for cocaine
A newborn infant is receiving immunization prior to discharge. Which action should the nurse implement?
Obtain signed consent from the mother for administration of hepatitis B vaccine
A term multigravida, who is receiving oxytocin (Pitocin) for labor augmentation, is requesting pain medication. Review of the clients record indicates that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the clients cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement?
Instruct the client to use deep breathing during a contraction
Which topic is most important for the nurse to include in a nutrition teaching program for pregnant teenagers?
Iron-deficieny anemia
When assessing an infant with severe diarrhea, the nurse should observe for which potential change in breathing pattern?
Kussmaul respirations
A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?
Last menstrual period 7 weeks ago.
A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the hcp of the clients condition, what information is most important for the nurse to provide?
Maternal Blood pressure
What snack is best to provide a 5-year-old child on prescribed bedrest while receiving treatment for osteomyelitis?
Milkshake
A mother brings her 3-year-old sone to the emergency room and tells the nurse that he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F (38.9 C). He is drooling and becoming increasingly more restless. What action should the nurse take first?
Notify the healthcare provider and obtain a tracheostomy tray
The nurse is caring for an infant scheduled for reduction of an Intussusception. The day before the scheduled procedure the infant passes a soft-formed brown stool. Which intervention should the nurse implement?
Notify the healthcare provider of the passage of brown stool
During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. What action should the nurse implement?
Notify the pediatrician of the cephalhematoma (THIS ONE DOES NOT CROSS THE SL & IS MORE CRITICAL)
While obtaining the vital signs of a 10-year-old child who has a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?
Inspect the posterior oropharynx
A toddler with nephrotic syndrome receives a prescription from the healthcare provider for enalapril. Which action should the nurse implement prior to administering the medication?
Observe fait and balance while ambulating
When administering indomethacin to a premature infant who has patent ductus arteriosus, the nurse should anticipate which outcome?
Decreased cardiac murmur
An 8-year-old male client with nephrotic syndrome is receiving salt-poor human albumin intravenously. Which findings indicate to the nurse that the child is manifesting a therapeutic response?
Decreased penorbital edema
The parents of a 4 week-old infant phone the pediatric clinic to report that their infant eats well but vomits after each feeding. To differentiate between normal regurgitation and pyloric stenosis, which information is most important for the nurse to obtain?
Degree of forcefulness of vomiting episodes
An adolescent with pelvic inflammatory disease (PID) is admitted to the hospital after 14 days of taking levofloxacin 500 mg orally daily and (medication) 500 mg twice daily. She asks the nurse, "Why do I have to be in the hospital? Why can't I get my treatment at home?" Which purpose should the nurse provide that supports an effective outcome?
Detection of early symptoms of Jarisch-Hersheimer reaction
The nurse is giving instructions to the mother of a 10-year-old boy who is newly diagnosed with type 1 diabetes mellitus (DM). When attempting to teach the mother how to administer subcutaneous insulin injections to the child, the mother tells the nurse she is afraid of needles and cannot perform the procedure. Which intervention should the nurse implement?
Determine if the child can administer the insulin
A 10-year-old girl who was bitten by a tick during a camping trip receives a prescription for tetracycline for Lyme's disease. Which information should the nurse provide to ensure the client understands?
Do not take tetracyclines with milk or antacids
An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?
Document in the client's record.
During a postpartum assessment of a client who is 5 hours post vaginal delivery, the nurse determines the fundus is 3 finger breadths above the umbilicus and positioned to the client's side. Which action should the nurse implement first?
Encourage the client to void
The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond?
Explain the newborns normal stepping reflex
A mother is concerned that her 3-year-old son wants to play with female doll figures. The child is not interested in building blocks, trucks or other typical "boy" toys. How should the nurse respond to the mother's concern?
Exploring different roles in imaginary play is typical at this age
Calculated by Naegele's rule, a primigravida client is at 28 weeks gestation. She is moderately obese and carrying twins and the nurse measures her fundal height at 27 cm. During the previous visit 3 weeks ago, the fundal height measured at 28 cm. Based on these findings, what should the nurse conclude?
Fundal height measurement may indicate intrauterine growth retardation
During a well-baby visit, the parents explain that a soft bulge appears in the groin of their 4-month-old son when he cries or strains during stooling. The infant is scheduled for surgical repair fo the inguinal hernia in two weeks. The parents should be instructed to take which measure if the hernia becomes (something) prior to surgery?
Gently manipulate the hernia for reduction
While auscultating the lung sounds of a 5-year-old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. Which action is best for the nurse to take?
Inquire about the use of alternative methods of treatment
A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30- hour labor. What is the priority nursing action for this client?
Observe for signs of uterine hemorrhage
The nurse is assessing a postpartum client who delivered a 10 pound infant vaginally two hours ago. The clients fundus is 2 fingerbreadths above the umbilicus, deviated to the right side, and boggy. After the client voids 250 ml of urine using a bedpan, what action should the nurse implement?
Palpate the suprapubic region for distention
At 40-week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take?
Place a wedge under the client's right hip.
The nurse is caring for a postnatal patient who is exhibiting symptoms of spinal headaches 24 hours following delivery of a normal newborn. Prior to anesthesiologist's arrival on the unit, which action should the nurse perform?
Place procedure equipment at bedside
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
Place the child in a quiet environment
The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?
Position a firm wedge to support pelvis and thorax at 30 degree tilt.
The nurse is assessing a 35 week primigravida with a breech presentation who is experiencing moderate uterine contraction every 3-5 minutes. During the examination the client tells the nurse, "I think my water just broke". Inspection of the perineal area reveals the umbilical cord protruding from the vagina. After activating the call bell system for assistance, what intervention should the nurse implement?
Position the client into a knee-chest position
A mother of a one month old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?
Position the infant on the stomach occasionally when awake and active
The nurse is admitting a child with a diagnosis of untreated hypoparathyroidism. Which finding indicative of hypocalcemia should the nurse report to the healthcare provider?
Positive Chvostek sign
A primigravida at 36-weeks gestation, who is Rh negative, experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the health care provider?
Positive fetal hemoglobin test
During a Women's Health Fair, which assignment is best for the practical nurse (PN) who is working with a registered nurse (RN)?
Prepare a woman for a bone density screening
A multiparous woman at 38-weeks gestation with a history of rapid progression of labor is admitted for induction due to signs and symptoms of preeclampsia. One hour after the Pitocin infusion is initiated, she complains of a headache. Her contractions are occurring every 1 to 2 minutes, lasting 60 to 75 seconds, and a vaginal exam indicates that her cervix is 90% effaced and dialted to 6 cm. What intervention is most important for the nurse to implement?
Prepare for immediate delivery
A multiparous client at 38- weeks gestation is admitted to labor and delivery with a compliant of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears a baby crying. What action should the nurse take first?
Push the call light for help
The school nurse is caring for a school-age child who was stung by a wasp on the playground. Which finding should prompt the nurse to call the emergency response team at 911?
Severe itching
A mother brings her male preschooler to the clinic because he has bad diarrhea, vomiting and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. What action should the nurse implement to get the child to cooperate?
Talk to the mother and gradually focus on the child's toy.
The nurse is educating an adolescent client about the important of regular vaccinations. Which vaccine should the nurse instruct the adolescent to receive every 10 years throughout adulthood?
Tetanus
A breastfeeding infant, screened for congenital hypothyroidism, is found to have lowlives of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding?
The TSH is high because of the low production of T4 by the thyroid.
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
The chorea or movements are temporary and will eventually disappear
The nurse is conducting an admission assessment of an 11-month-old infant with hear failure who is scheduled for repair of stenosis of concentration at the aorta that was repaired 4 days after birth. Findings include blood pressure higher in the arms than the lower extremities, pouncing brachial pulses, and slightly palatable femoral pulses. Which pathophysiologic mechanism supports these findings?
The lumen of the aorta reduces the volume of blood flow to the lower extremities.
A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide?
This hernia is a normal variation that resolves without treatment.
A client at 20 weeks gestation comes to the antepartum clinic complaining of vaginal warts (human papillomavirus). What information should the nurse provide this client?
Treatment options, while limited due to the pregnancy, are available
A client who is receiving oxytocin (Pitocin) to augment early labor begins to experience hypersystolic or tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement? Reposition the fetal monitor transducers
Turn off the Pitocin infusion
A client who is in active labor is receiving magnesium sulfate and begin to experience slurred speech and decreased reflexes. Which action should the nurse implement first?
Turn off the magnesium sulfate infusion
After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborns diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
Turn the newborn to the side and bulb suction the mouth and nares
How should the nurse instruct the parents of a 4-month-old with sebotheic dermatitis (cradle cap) to shampoo the child's hair?
Use a soft brush and gently scrub the area
During a well baby clinic visit, the mother of a 6-month-old infant asks the nurse if she can have a prescription for Poly VI Sol with fluoride. Though the infant is still breast feeding, the mother provides the child with supplemental formula feedings. Which assessment is most important for the nurse to obtain?
Water source used with supplemental feedings
At 34- weeks gestation, a primigravida is assessed at her bimonthly clinic visist,. Which assessment finding is important for the nurse to report to the hcp?
Weight gain of 7 pounds
A client at 33- weeks gestation is admitted with a moderate amount of vaginal bleeding and no contractions are noted on the external monitor. Which intervention should the nurse implement?
Weight perineal pads
A client who delivered a healthy newborn an hour ago asks the nurse when can she go home. Which information is most important for the nurse to provide the client?
When there is no significant vaginal bleeding
