unit 4 holistic fall 2022 exam pt 1
What is the most important action by the practical nurse (PN) in preventing neonatal infection? Hand washing. Isolating infected infants. Adequate spacing of bassinets. Practicing Standard Precautions. Submit
a
A 3-day old newborn who weighed 7 pounds, 8 ounces at birth is breast feeding and now weighs 6 pound and 15 ounces. Which action should the practical nurse take? Provide supplemental formula feedings. Document the weight loss. Review admission assessment findings. Maintain strict intake and output.
b
Which client is a candidate for the administration of human immune globulin (RhoGam) after delivery? The Rh-positive mother who delivers a Rh-positive baby. The Rh-negative mother who delivers a Rh-negative baby. The Rh-positive mother who delivers a Rh-negative baby. The Rh-negative mother who delivers a Rh-positive baby.
d
Which information should the practical nurse (PN) provide the parents about the purpose of instilling erythromycin (Ilotycin) ophthalmic ointment into the newborn's eyes? Prevents the infant's eyelids from sticking together. Destroys Staphylococcus overgrowth in eye exudate after birth. Prevents obstruction of the infant's tear ducts. Prophylactic treatment for gonorrheal and chlamydia infection.
d
Which medication is prescribed for the prevention of ophthalmia neonatorum? Triple antibiotic ointment (Neosporin). Natamycin (Natacyn). Tobramycin (Tobrex). Erythromycin (Ilotycin).
d
Which strategy should the practical nurse (PN) implement to prevent a puerperal infection for a client during the first postpartum week? Administer prophylactic antibiotics. Give mega-doses of vitamin C. Provide perineal care and pad change every 2 hours. Implement strict medical and aseptic technique. Submit
d
Which intervention should the practical nurse (PN) provide a neonate during hospitalization? Provide play activities in the hospital room. Offer the neonate a pacifier between feedings. Assign the neonate to a room with other neonates. Request that parents bring security object from home.
b
A multiparous client's membranes rupture after 8 hours of labor. Which action should the practical nurse implement at this time? Notify the client's healthcare provider. Prepare the client for imminent birth. Document the characteristics of the fluid. Assess the fetal heart rate (FHR) and pattern. Submit
d
A primigravida client asks the practical nurse (PN), "How will I know that I will be going into labor soon?" Which sign should the PN provide that is a common sign? Burst of energy. Urinary retention. Increase in fundal height. Weight gain of 1.5 to 2 kg. Submit
a
The practical nurse (PN) is discussing aspects of newborn hygiene with the new parents as they prepare for discharge. Which information should the PN provide? Cleanse the ears and nose with cotton-tipped swabs. Wash the baby's head once a week. Begin tub baths when the cord is dried. Create a draft-free environment when bathing the baby.
d
The practical nurse (PN) is reviewing the informational packets with a client who is at risk for preeclampsia. Which information is most important for the PN reinforce with the client? Notify the clinic if any vision changes are experienced. Rest frequently with both feet elevated after long periods of standing. Pack personal belongings for admission to the hospital. Record daily weight for review by the healthcare provider at the next visit.
a
The practical nurse (PN) palpates fundal height at the umbilicus of a multiparous client who has just given birth to an 8-pound boy when dark red blood comes from the client's vagina. What action is most important for the PN to implement? Continue to massage the fundus until firm. Obtain serial vital signs every 15 minutes. Observe the perineum for hematoma formation. Determine if clots have formed in the lochia. Submit
a
The practical nurse (PN) quickly moves the crib of a male newborn and notices that his legs flex, arms fan out, and then return toward his midline. What action should the PN implement? Document the newborn demonstrates a Moro reflex. Report the abnormal finding to the charge nurse. Perform a hearing test for the newborn. Observe for other abnormalities in the musculoskeletal system.
a
Which finding for a 2-week-old infant should the practical nurse (PN) report to the healthcare provider? Yellowish tinge around the eyes. Peeling skin on the trunk. Cool hands compared to body core. Small pink patch at base of the neck.
a
The practical nurse (PN) is assessing a client 2 hours after a vaginal delivery of a 7-pound 3-ounce newborn and determines the client's bladder is distended. Which additional finding should the PN report to the charge nurse? Multiple straight catheterizations during labor. Fundus is 3 cm below the umbilicus. Inability to initiate the urinary stream. Excessive bleeding on the perineal pad.
d
A primigravida client who is at 39-weeks gestation arrives at the clinic and tells the practical nurse (PN) she is having contractions every 5 minutes. The healthcare provider determines she is dilated 3 cm and in early labor. What action should the practical nurse (PN) implement when the client groans with each contraction? Assist the client to the bathroom to void. Give a prescribed narcotic analgesic. Document the maternal vital signs. Demonstrate simple relaxation measures. Submit
d
A 14-week gestational client, who weighed 125 pounds before pregnancy, comes into the health clinic for a prenatal appointment. The client's weight today is 129 pounds. What action should the practical nurse (PN) implement? Document the finding in the medical record. Retake the weight after calibrating the scale. Notify the healthcare provider. Obtain a 24-hour dietary recall.
a
After repeating the vital signs for a newborn who is 4 hours old, the practical nurse (PN) obtains an axillary temperature of 97.2 F and places the newborn under a radiant heat warmer. Which additional finding should the PN observe in the newborn? Tremors of the hands during crying. An increase in heart rate. Flushing of the skin. Respiratory depression. Submit
a
A client who is 5 weeks pregnant calls the clinic to report that her home pregnancy test is positive. She asks what she should be concerned about during the weeks before her first visit. Which signs and symptoms should the practical nurse (PN) tell the client to report immediately to the healthcare provider? (Select all that apply.) Select all that apply Vaginal bleeding. Decreased libido. Urinary frequency. Membrane rupture. Severe headaches.
ade
Which physiological cause(s) for constipation during pregnancy should the practical nurse (PN) explain to a client in the first trimester? (Select all that apply.) Select all that apply Displacement of the colon. Tightening of the anal sphincter. Change in nutrient absorption. Shifting of liver placement. Decrease in peristalsis. Increase bile production.
ae
A mother who is preparing for discharge begins asking the practical nurse (PN) questions about bottle feeding her infant. What information should the PN reinforce? Place leftover formula in the refrigerator for 24 hours only. Burp the newborn periodically during the feeding. Heat the bottle of formula in the microwave oven. Add extra formula powder to increase the concentration. Submit
b
A young adult female comes to the health clinic to confirm a positive home pregnancy test. After determining the client's last menstrual period (LMP) as August 5, what expected date of birth (EDB) should the practical nurse (PN)calculate? April 29. May 12. July 1. June 12.
b
The practical nurse (PN) places a newborn who is 4 hours old with an axillary temperature of 97.2 o F under the radiant heat warmer. Which rationale supports the PN's action? Heat loss increases as the newborn stretches from a flexed position. The newborn's thin layer of subcutaneous fat provides poor insulation. The basal metabolic rate is higher in a neonate that an adult. Neonatal body surface area allows for a slower rate of heat loss.
b
A client who took iron supplements during pregnancy delivers an infant by cesarean section. On the second postpartum day, the client reports having a constipated stool that is greenish-black in color. Which action should the practical nurse (PN) implement? Collect a stool sample for guaiac testing. Administer a prescribed rectal suppository. Record color and consistency of the stool. Report the complaints to the charge nurse.
c
A primiparous client asks the practical nurse (PN) how much her newborn baby boy should sleep every day. What information should the PN provide? The newborn should be allowed to sleep until he wakes up crying and hungry. Keep the baby awake during the daytime so he sleeps through the night. A newborn sleeps most of the day and gradually will have increasing periods of wakefulness. Expect your baby to follow your sleep and wake patterns once you establish a pattern at home.
c
An infant who weighs 4550 grams is delivered using forceps-assisted vaginal delivery. What action is most important for the practical nurse (PN) to implement? Palpate the clavicle for irregularity. Place the infant to the mother's breast. Monitor for signs of hypoglycemia. Complete a gestational age assessment.
c
The mother asks the practical nurse (PN) what her infant may need if the phenylketonuria (PKU) test is positive. What type of treatment should the PN tell the mother will be required? Blood transfusions. Iron-enriched formula. Lifelong dietary management. Medications to prevent infection.
c
Which client should the practical nurse (PN) closely monitor for severe afterpains? A mother who had oligohydramnios during the pregnancy. A primiparous client who is bottle feeding. A multigravida who is breastfeeding. A primigravida who delivered a 5 pound 3 ounce infant. Submit
c
A father expresses concern that his 3-day-old infant looks "yellow." Which information should the practical nurse (PN) provide? This yellow skin condition is the result of hepatic insufficiency. Normal signs of jaundice occur during the first 24 hours of life. Blood incompatibilities between mother and infant blood are common. Physiologic jaundice occurs from a normal reduction in red blood cells.
d
A primigravida at 33-weeks gestation is admitted after being involved in a motor vehicle collision (MVC). The client has no complaints of abdominal pain and no evidence of vaginal bleeding. Which action should the practical nurse (PN) anticipate implementing for the client? Transfer to a trauma unit. Monitor a ruptured spleen. Prepare for Cesarean section. Obtain a biophysical profile.
d