418 Exam 1
A nurse in a provider's office enters an examination room to assess an 8-month-old infant for the first time. Which of the following reactions by the infant should the nurse expect? A. The infant gives the nurse a social smile B. The infant turns away when the nurse approaches C. The infant reaches out to the nurse to be held D. The infant is responsive and alert as the nurse comes closer
ANS: B. The nurse should expect the 8-month-old infant to have a heightened fear of strangers. The infant is expected to cling to their parent and turn away when approached by a stranger. Infant = Trust vs Mistrust
A nurse is teaching a client who is at 8 weeks gestation and has uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following pieces of information should the nurse include? A. "The fibroid will shrink during the pregnancy." B. "The fibroid can increase the risk of postpartum hemorrhage." C. "You will receive an injection of medroxyprogesterone acetate to shrink the fibroid." D. "You will have to undergo a cesarean birth because of the fibroid.
ANS: B. Uterine fibroids can increase the risk of postpartum hemorrhage due to the increased blood supply to the uterus, which supports the fibroid.
A nurse is caring for a client in the early stage of labor who has preeclampsia with severe features. Which of the following interventions should the nurse perform? A. Assess the fetal heart rate and contractions hourly B. Encourage oral intake of clear, low-sodium fluids C. Instruct the client to ambulate during the early phase of labor. D. Implement seizure precautions
ANS: D. Clients who have preeclampsia with severe features are at risk of seizures. The nurse should keep the side rails of the client's bed up and ensure oxygen and suction equipment are readily available.
A postpartum nurse is preparing to care for a client who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the client's vital signs: A. every 30 minutes during the first hour and then every hour for the next 2 hours. B. every 15 minutes during the first hour and then every 30 minutes for the next 2 hours. C. every hour for the first two 2 hours and then every 4 hours. D. every 5 minutes for the first 30 minutes and then every hour for the next 4 hours
B. every 15 minutes during the first hour and then every 30 minutes for the next 2 hours.
Nurse is reviewing new prescription for iron supplements with client who is 8 weeks gestation and has iron deficiency. Which following beverages should nurse instruct to take with iron supplements? a. ice water b. low fat or whole milk c. tea or coffee d. orange juice
d. orange juice orange juice helps iron absorption
1 lb equals how many kg?
0.454kg
how many oz in 30mL?
1 oz
15 mL is how many tablespoons
1 tbsp
how many teaspoons in 5 mL
1 tsp
How many cm in 1 inch
2.54
A nurse is planning a smoking cessation program for women of childbearing age. Which of the following risks is associated with smoking during pregnancy? A. Infant developmental delays B. Maternal osteoporosis C. Maternal ulcers D. Infant lung cancer
A. Infant developmental delays
A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect? A. Abduction and extension of the arms asymmetric. B. The opposite leg flexes while a leg is extended and the sole of the foot is stimulated. C. Toes hyperextend with dorsiflexion of the great toe. D. The legs move in a similar pattern of response to the arms.
ANS. D. Symmetric movement of the arms and legs is an expected findings when assessing the Moro reflex. If the arms move up, the legs are expected to move up as well
A nurse is planning care for a 3-month-old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan? A. Avoid laying the infant on his abdomen B. Avoid tucking the appliance into the infant's diaper C. Check the bag for stool every 4 hours D. Replace the appliance every 3 day
ANS: C. The nurse should check the bag for stool every 4 hrs or less to prevent the bag from overfilling and leaking. Stool from an ileostomy is acidic and can cause excoriation of the skin. The infant can lie on their abdomen because the ostomy has no nerves, which means it will not cause pain. The nurse should tuck the ostomy appliance into the infant's diaper to prevent accidental removal. The nurse should plan to replace the appliance once a week. Frequently changing the appliance increases the risk of injury to the skin surrounding the stoma
A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will not dress my child in a 1-piece outfit" B. "I need to buy diapers that are tighter than those my infants usually wears." C. "I need to apply paste to the back of the wafer on my child's appliance." D. "I will not need to toilet train my child."
ANS: C. The parent should apply stoma paste to the back of the wafer on the appliance and around the stoma. This paste will act as a sealant to prevent skin breakdown.
Which of the following behaviors would be under the category "grimace" in the Apgar score? Select all that apply. A. Sneezing B. Grasping C. Coughing D. Pulling away
Correct: A, C, D
A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places infants at a higher risk of electrolyte imbalances compared to an adult client? A. Less extracellular fluid B. Reduced body surface area C. Longer intestinal tract D. Decreased rate of metabolism
NS: C. Compared to adults or older children, infants have a longer intestinal tract. This results in greater fluid losses, especially through diarrhea. Infants also have a larger amount of extracellular fluid, a larger body surface area, and an increased rate of metabolism
A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by quickly and gently turning the newborn's head to one side? A. Rooting B. Moro C. Tonic neck D. Babinski
NS: C. To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when the newborn is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turned the head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months.
The nurse is preparing to administer medication to a 16-year-old client. What actions should the nurse take? Select all that apply. Locate stickers to reward the client for cooperating with the med administration. a.Work with the client to plan a schedule for taking the medications. b.Locate a pamphlet about the medication written at a high school reading level. c.Prepare a dropper so the medication can be placed to the side and back of the mouth. d Locate stickers to reward the client for cooperating with the med administration.
Work with the client to plan a schedule for taking the medications. Locate a pamphlet about the medication written at a high school reading level.
Nurse is caring for a client who is pregnant and states last menstrual period was April 1st. Which is estimated date of delivery? a. Jan 8th b. Jan 15th c. Feb 8th d. Feb. 15th
a. Jan 8th
A nurse is caring for a client having contractions every 8 min that are 30-40 sec in duration, clients cervix is 2 cm dilated fetus is at -2 station with FHR 140/min. which of the following stage and phase of labor is this client in? a. first stage, latent phase b. first stage, active phase c. first stage, transition phase d. second stage of labor
a. first stage, latent phase
Prenatal clinic nurse caring for 4 clients. Which of the following clients weights gain should the nurse report to the provider? a. 1.8 kg (4lbs) gain in first trimester b. 3.6kg (8lb) gain in first trimester c. 6.8 kg (15lb) gain in second semester d. 11.3 kg (25lb) gain in third semester
b. 3.6kg (8lb) gain in first trimester 3-4 lbs. is recommended in the first trimester
Client who is 8 weeks gestation tells the nurse she is not happy about being pregnant. How should the nurse respond? a. I will inform the provider that you are having these feelings b. Its normal to have these feelings during the first few months of pregnancy c. you should be happy you are going to bring a new life into the world d. i am going to make an appointment with a counselor for you to discuss these thoughts
b. Its normal to have these feelings during the first few months of pregnancy
Nurse is caring for group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to genetic counselor? a. clients sister who has alopecia b. client whose partner has von Willebrand disease c. Client who has allergy to sulfa d. client who had rubella 3 months ago
b. client whose partner has von Willebrand disease Willebrand disease is a genetic bleeding disorder
The nurse is preparing to administer medication to a 2-year-old client. What actions should the nurse take? Select all that apply. a. carefully explain how the medication works and why they are given. b.Find out from the client's parents what words the client uses at home. c. Check for loose teeth to see if chewable meds should be avoided. d. Smile and say "great job" with enthusiasm for cooperation.
b.Find out from the client's parents what words the client uses at home. d. Smile and say "great job" with enthusiasm for cooperation.
Nurse is teaching clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include? (SATA) a. Avoid any lifting b. Perform Kegel exercises twice a day c. Perform pelvic rock exercise every day d. use proper body mechanics e. avoid constrictive clothing
c. Perform pelvic rock exercise every day d. use proper body mechanics
Prenatal clinic nurse caring for pregnant client experiencing episodes of maternal hypotension. Client asks what causes these episodes. Which of the following responses should nurse make? a. due to increase in blood volume b. due to pressure from uterus on diaphragm c. due to weight on uterus on the vena cava d. increased cardiac output
c. due to weight on uterus on the vena cava when client is lying supine weight of uterus decreases blood flow to heart
an ob nurse is teaching a clinic about IUD contraception. which statement indicates understanding? a. an IUD should be replaced annually during pelvic exam b. I cant get and IUD until after I've had a child c. I should plan on regaining fertility 5 months after IUD is removed d. I will check to be sure the strings of IUD are still present after my periods
d. I will check to be sure the strings of IUD are still present after my periods
Nurse is reviewing postpartum nutrition needs with group of clients who have begun breastfeeding. Which of the following statements by a member of the group indicates understanding? a. Im glad I can have my morning coffee b. i should take folic acid to increase my milk supply c. i will continue to add 300 calories per day to my diet d. i will continue calcium supplement because I don't like milk
d. i will continue calcium supplement because I don't like milk clients who are at risk of inadequate dietary calcium should take calcium supplement during breastfeeding
Nurse is teaching patients of childbearing age about folic acid supplements. Which of the following defects can occur in fetus or neonate as a result of folic acid deficiency? a. iron deficiency anemia b. poor bone formation c. macrosomic fetus d. neural tube defects
d. neural tube defects
A nurse is performing a physical assessment of a full-term newborn and eliciting the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply). A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward. C. Arms and legs adducting D. Arms falling backwards after startling E. Head turning to the right.
ANS: A and B. A "C" formation of the thumb and forefinger and an extension of the legs before pulling upward are expected components of the Moro reflex. This response is present at birth and absent by 6 months of age in neurologically intact infants.
A nurse is planning cares for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply). A. Observe the parents' actions when feeding the child. B. Maintain a detailed record of food and fluid intake C . Follow the child's cues to time food and fluids D.Sit beside the child's high chair for feedings E. Play music videos during scheduled meal times
ANS: A and B. Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. A nutritional goal for this child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake.
A nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? A. Absent tears B. Weight loss >10% C. Lethargy D. Dry mucous membranes
ANS: D. Dry mucous membranes are an expected finding of moderate dehydration. Absent tears, weight loss of >10%, and lethargy are all findings for severe dehydration
A nurse is caring for a newborn. The nurse should obtain informed consent before taking which of the following actions? A. Administering erythromycin ophthalmic ointment B. Conducting a newborn hearing screening. C. Giving the hepatitis B vaccine D. Screening for critical congenital heart disease.
C. The nurse must obtain informed consent from the newborn's guardian before administering the hepatitis B vaccine.
A client who is pregnant tells the nurse that she is financially unable to buy the food and vitamins recommended during pregnancy. Which of the following actions should the nurse take? A. Explain to the client that improper nutrition could lead to birth defects in her baby. B. Instruct the client to return to the clinic for weekly weigh-ins for the remainder of the pregnancy. C. Provide the client with sample menus to promote nutritious meal preparation. D. Refer the client to a community resource that could assist with providing nutrition
ANS: D. Federal and state programs are available to provide financial assistance that allows pregnant women and families with young children to purchase nutritious foods.
Nurse is caring for post op client following salpingectomy due to ectopic pregnancy. Which of the following statements by the client requires clarification? a. its good to know i won't have a tubal pregnancy in the future b. doctor said surgery can affect my ability to get pregnant again c. i understand that one of my fallopian tubes had to be removed d. ovulation can still occur because my ovaries were not affected
a. its good to know i won't have a tubal pregnancy in the future
The nurse in the infertility clinic is providing care to clients who have been unable to conceive for 18 months. Which data should the nurse assess? (SATA) a. occupation b. menstrual history c. childhood infectious diseases d. history of falls e. recent blood transfusions
a. occupation b. menstrual history c. childhood infectious diseases
Nurse is caring for pregnant client and reviewing manifestations of complications client should report promptly. Which should the nurse include? a. vaginal bleeding b. swelling of the ankles (CANKLES) c. heartburn after eating d. lightheadedness when lying on back
a. vaginal bleeding
A prenatal clinic nurse caring for a client in 1st trimester. Clients health record includes: G3 T1 P0 A1 L1. How should nurse interpret this data? (SATA) a. Client has delivered one newborn at term b. Client has experienced no preterm birth c. client has been through active labor d. client has had 2 prior pregnancies e. client has one living child
a. Client has delivered one newborn at term d. client has had 2 prior pregnancies e. client has one living child
Nurse is caring for a couple who is being evaluated for infertility. Which statements by nurse indicates understanding of infertility assessment process? a. you will need to see a genetic counselor as part of the assessment b. its usually the female who is having trouble, males doesn't have to be involved c. male is easiest to assess and provider usually begins there d. think about adopting first because there are many babies that need good homes
c. male is easiest to assess and provider usually begins there sperm assessment usually done first
A nurse is instructing a who is taking oral contraceptives about side effects to report to PCP. Which should the nurse include? a. reduced mensural flow b. breast tenderness c. shortness of breath d. increase appetite
c. shortness of breath
Clinic nurse receives call from a client who would like to be tested to confirm pregnancy. Which following information should the nurse provide? a. you should wait till 4 weeks after conception to be tested b. should be off any meds for 24 hour prior to test c. you should be NPO for 8 hours prior to test d. you should collect urine from first morning void
d. you should collect urine from first morning void
A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the lab values? A. "The infant might be dehydrated." B. "The infant might be anemic" C. "The infant might have received too much fluid" D. "The infant might have leukemia"
ANS: A. An increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration. The hemoglobin is within the expected range, thus, they don't have anemia. Overhydration would result in a decrease in hematocrit level. Leukemia presents with a high WBC count and a low RBC count.
A nurse is assessing an adolescent who has appendicitis. Which of the following manifestations should the nurse expect? A. Upper right quadrant abdominal pain B. Rigid abdomen C. Hyperactive bowel sounds D. Bradycardia
ANS: B. A rigid abdomen is an expected finding for appendicitis. Other manifestations include lower right quadrant abdominal pain, decreased or absent bowel sounds, tachycardia, and rapid, shallow breathing
A nurse is caring for a client who is in labor. The nurse decides to switch from intermittent auscultation to continuous fetal monitoring. Which of the following data can only be obtained from continuous electronic fetal monitoring? A. Determination of a baseline B. Determination of variability C. Presence of accelerations D. Presence of decelerations
ANS: B. Continuous electronic fetal monitoring is required to determine variability since the nurse needs a monitor tracing to quantify variability
A nurse is discussing the expected changes related to pregnancy with a client who is at 8 weeks gestation. Which of the following findings should the client report to the provider during the first trimester? A. Breast tenderness B. Urinary frequency C. Persistent vomiting D. No fetal movement
ANS: Intermittent nausea and vomiting during the first trimester are common. However, the nurse should inform the client that persistent vomiting suggests hyperemesis gravidarum and increases the risk of fluid and electrolyte imbalance. In this situation, maternal and fetal health might be compromised, and symptoms should be reported to the provider. The cause of hyperemesis gravidarum is unknown but might result from human chorionic gonadotropin (hCG) levels. The client should be encouraged to eat dry crackers upon awakening, eat 5-6 small meals daily, and avoid fried, odorous, or spicy foods.
A nurse in a health clinic is reviewing contraceptive use with a group of clients. Which of the following clients statements demonstrates understanding? a. a water soluble lub should be used with condoms b. a diaphragm should be removed 2 hrs after sex c. oral contraceptives can worsen acne d. contraceptive patch is replaced once a month
a. a water soluble lub should be used with condoms
Nurse reviewing health record of pregnant client. Provider indicates client exhibits probable signs of pregnancy. Which of the following findings would the nurse expect? (SATA) a. Montgomery's gland b. Goodall's sign c Ballottement d. Chadwick's sign e. quickening
b. Goodall's sign c Ballottement d. Chadwick's sign
A nurse is caring for a client who has a BMI of 22.6 and expresses concerns about weight gain during pregnancy. Which of the following responses should the nurse make? A. "You're eating for 2, so you should double your caloric intake. B. "You'll lose weight easily after the birth of your baby." C. "Plan to gain a total of 15 to 20 pounds during pregnancy." D. "Gaining weight will promote a healthy pregnancy."
ANS: D. A weight gain of 11.3 to 15.9 kg (25-30lb) during pregnancy is essential for supporting the growth and development of the fetus. Limiting caloric intake results in using fat stores for energy and developing ketonemia, which is a risk factor for preterm labor.
Nurse teaching a client who is 6 week gestation about common discomforts of pregnancy. Which should the nurse include? (SATA) a. breast tenderness b. urinary frequency c. epistaxis d. dysuria e. epigastric pain
a. breast tenderness b. urinary frequency c. epistaxis
Prenatal clinic nurse providing ed to a client 8 weeks gestation. client states she doesn't like milk. Which of the following should the nurse recommend as a good source of calcium? a. dark green leafy veggies b. deep red and orange veggies c. white bread and rice d. meat, poultry, and fish
a. dark green leafy veggies
Client is 7 week gestation experiencing N/V in the am. Which information should nurse provide? a. eat crackers or plain toast before getting out of bed b. awaken during night to eat a snack c. skip breakfast and lunch after nausea subsided d. eat a large evening meal
a. eat crackers or plain toast before getting out of bed
A nurse is reviewing medical record of client who had hysterosalpingography. which of the following data alert the nurse the client is at risk for complication related to this procedure? Vital signs: T:97F HR 60/min HX & Physical: employed radiology tech allergy to shrimp tonsillectomy age 18 Lab findings: glucose 103/mg/dL Hgb: 13.1 g/dL Total Cholesterol 265mg/dL Meds Rosuvastatin Magnesium Oxide Mafenide acetate a. vitals b. history and physical c. lab findings d. meds
b. history and physical allergy to shrimp is contraindicated to dye used
A nurse is teaching about potential adverse effect's of implantable progestins. Which should be included (SATA) a. tinnitus b. irregular vag bleeding c. weight gain d. nausea e. gingival hyperplasia
b. irregular vag bleeding c. weight gain d. nausea
A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C. FLACC D. PIPP
ANS: C. The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age
A nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect? A. The fundal height measures greater than gestational age. B. A rigid abdomen is noted on palpation. C. The client reports a pain level of 8 on a 0-10 pain scale. D. A urine drug screen is positive for cocaine
ANS: A. Clients with placental previa often measure slightly larger than expected because the fetus remains higher in the uterus. Clients with placenta previa present with a soft, non-tender abdomen. A rigid abdomen and severe abdominal pain are associated with placental abruption.
A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority? A. Measure the client's weight daily B. Check for tears C. Palpate the fontanel D. Assess skin turgor
ANS: A. Daily weight measurements are the most sensitive indicator of fluid balance in clients of all ages. Daily weight measurements are especially critical for infants and children because fluid accounts for a greater portion of body weigh
A nurse is caring for a client who asks, "How will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make? A. "True contractions will begin irregularly and then become regular in timing." B. "True contractions will go away with ambulation." C. "False contractions increase in frequency and duration the closer you are to your due date." D. "False contractions are first felt in the pelvic area and then in the lower back and abdomen."
ANS: A. False contractions begin and remain irregular, but true contractions will begin irregularly and become regular and predictable
A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect? A. Painless, bright red bleeding. B. Board-like uterus C. Persistent uterine contractions D. Abdominal pain
ANS: A. Placenta previa is the placement of the placenta low in the uterus. Depending on the severity, manifestations include bright red vaginal bleeding and a fundal height higher than expected for gestational age. The presenting part is higher due to the placenta taking up space inside the lower part of the uterus.
A nurse is providing teaching about immunization schedules to the parents of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching? A. "Initial vaccines should be administered between birth and 2 weeks of age." B. "Your child will need to begin the vaccination series over again if subsequent doses in the series are missed." C. "An allergic reaction to a vaccine due to the active ingredient in the vaccine." D. "A vaccination should be postponed if your child has a rectal temperature of 99.5F and head congestions
ANS: A. The first dose of the hepatitis B vaccine should be administered within the first 2 weeks after birth. The dose should be given befdischargehage from the hospital if the mother is hepatitis B surface antigen (HBsAg) negative. If a client receives an initial dose in a series but misses a subsequent dose, the client will not need to begin the series again. The client should receive the missed dose as soon as possible. Allergic reactions to vaccines are most often caused by the inactive parts of the vaccines, which are used to enhance the effectiveness of the vaccine. Ex of inactive ingredients is purified culture medium proteins such as egg or antibiotics such as neomycin. A vaccine does not need to be postponed for minor illnesses such as a common cold. A rectal temp of 37.5C (99.5F) is considered within the normal range. However, all immunization should be postponed for a severe febrile illness.
A nurse is caring for a client who is at 33 weeks of gestation and reports dark red vaginal bleeding and contractions that do not stop. Which of the following actions should the nurse take first? A. Check the fetal heart tones B. Assess the uterine contraction pattern C. Measure maternal vital signs D. Obtain a biophysical profile
ANS: A. The greatest risk to the client is fetal mortality from placental abruption; therefore, the priority assessment is immediate auscultation of fetal heart tones to determine the status of the fetus
A nurse is performing a physical assessment on a 12-month-old infant. Which of the following findings should the nurse report to the provider? A. The infant's current weight is double his birth weight. B. The infant's posterior fontanel is closed C. The infant is unable to walk without support D. A total of 6 teeth are present.
ANS: A. The nurse should expect a 12-month-old infant's weight to be triple his birth weight; therefore, the nurse should report this finding to the provider. The nurse should expect the infant's posterior fontanel to be closed at about 2 months of age. The nurse should not expect the ability to walk until the infant is 13-15 months of age. The nurse should expect a 12- month-old infant to have 6-8 teeth present.
A nurse is providing teaching to the guardians of an infant who has failure to thrive (FTT). Which of the following pieces of information should the nurse include in the teaching? A. Add fortified rice cereal to the infant's formula B. Alternate feedings between several family members C. Offer the infant juice between feedings D. Provide feedings on demand rather than on a schedule
ANS: A. The nurse should inform the guardians that adding fortified rice cereal or vegetable oil to the infant's formula helps promote weight gain.
A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer? A. Betamethasone. B. Misoprostol C. Methylergonovine D. Poractant alfa
ANS: A. The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and prevent respiratory depression
A nurse is caring for a client who is at 38 weeks gestation and reports no fetal movements for the past 24 hours. Which of the following actions should the nurse take? A. Auscultate for a fetal heart rate. B. Have the client drink orange juice C. Reassure the client that a term fetus is less active D. Palpate the uterus for fetal movement
ANS: A. The presence of fetal heart rate is reassuring manifestation of fetal wellbeing. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action. Orange juice can help stimulate a sleeping fetus; however, the client had not felt movement for 24 hrs. Lack of fetal movement in 24 hr is not an expected finding. Palpating for fetal movement is not a reliable method of determining fetal well-being.
A nurse in a prenatal care clinic answers a phone call from a client who is at 37 weeks gestation and reports, "I become very dizzy while lying in bed this morning, but the feeling went away when I turned onto my side." Which of the following actions should the nurse take? A. Instruct the client about vena cava syndrome and measures to prevent it. B. Arrange for the client to come to the clinic for an assessment C. Check the client's chart for gestational diabetes mellitus D. Schedule a nonstress test for the client
ANS: A. This is a typical finding of vena cava syndrome or hypotension that occurs in clients who are pregnant upon assuming a supine position. It is caused by compression of the inferior vena cava by the gravid uterus with a consequent reduction in venous return. A side-lying position promotes uterine perfusion and fetoplacental oxygenation.
A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? A. 480 mL urine output in 24 hr B. Blood pressure 144/92 mmHg C. 2+ edema of the feet D. 1+ protein in urine
ANS: A. This is the priority finding because the minimum acceptable urine output for an adult is 30mL/hr. This can indicate the worsening condition or progression of preeclampsia to severe preeclampsia, which requires immediate intervention. The blood pressure at 144/92, 2+ edema of the feet, and 1+ protein in the urine are all expected findings for a client with preeclampsia. They are not the priority findings to report.
A nurse is reviewing the medical record of a client at 33 weeks gestation who has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider? A. Perform a vaginal examination. B. Perform continuous external fetal monitoring C. Inset a large-bore IV catheter D. Obtain a blood sample for laboratory testing.
ANS: A. When a client has placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding.
A nurse is reviewing findings of a client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? (Select all that apply). A. Fetal weight B. Fetal breathing movement C. Fetal tone D. Fetal position E. Amniotic fluid volume
ANS: B, C, and E. The five categories for BPP are fetal heart rate (FHR), fetal breathing movements, gross body movements, fetal tone, and qualitative amniotic fluid volume.
A nurse is planning care for a client in active labor whose fetus is in an occipital brow presentation. Which of the following complications should the nurse anticipate as a result of this fetal presentation? A. Precipitous labor B. Prolonged labor C. Hypertonic uterine dysfunction D. Umbilical cord prolapse
ANS: B. An occipital brow presentation increases the diameter of the presenting part, which may prevent the fetal head from descending into the pelvis. This can result in prolonged labor, forceps - or vacuum-assisted birth, or a c-section delivery.
The nurse is teaching a client who is postpartum about rubella vaccine. Which of the following statements should the nurse include? A. "You must not take this immunization if you've had the chickenpox." B. "You must not become pregnant for 28 days after receiving this immunization." C. "You must not breastfeed because the virus is passed in breastmilk." D. "You must not receive other vaccines at the same time as the rubella vaccine."
ANS: B. Clients must not become pregnant for 28 days following rubella immunization. They should be educated about the possible side effects and risk of teratogenic effects on the developing fetus.
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A. Varicose veins B. Double vision C. Leukorrhea D. Flatulence
ANS: B. Double vision, blurred vision, or visual disturnnances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider.
A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider? A. Platelet count 97,000/mm^3 B. Deep tendon reflexes 4+ C. Urine protein 1+ D. BUN 22mg/dL
ANS: B. Hyperactive deep tendon reflexes demonstrate a progression from mild preeclampsia to severe gestational hypertension or preeclampsia with severe features. This finding indicates the need for hospitalization and treatment with magnesium sulfate to prevent eclamptic seizu
A pregnant mother with gestational diabetes places the newborn in which of the following risk? A. Hypercalcemia B. Hypoglycemia C. Infection D. Birth trauma
ANS: B. Newborns of mothers who have gestational diabetes are at risk for hypoglycemia. The nurse should monitor the newborn following birth.
A nurse is assessing a 3-year-old who is 1-day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? A. Ask the parents B. Use the FACES scale C. Use the numeric rating scale D. Check the child's temperature
ANS: B. Pain is a subjective experience, even for a 3-year-old child. The FACES scale can be used to determine the presence of pain in children as young as 3 years of age.
A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine growth
ANS: B. Progesterone maintains the lining of the uterus, which maintains the pregnancy. It also reduces uterine contractility. A client who has a low progesterone level is at risk of preterm labor.
A nurse is performing a well-child assessment on a 7-year-old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development? A. Initiative vs guilt B. Industry vs inferiority C. Identity vs role confusion D. Autonomy vs shame and doubt
ANS: B. The developmental task of industry vs. inferiority is reflected by a child's level of motivation in relation to personal achievements that build good character during the school-age years (age 6-12 years)
A nurse is teaching a client who is pregnant about nonstress testing. Which of the following pieces of information should the nurse include? A. "The test is an invasive procedure that presents minimal risk to the fetus." B. "If the test is reactive, that means your baby's heart rate is healthy." C. "When your baby moves, the test should record the baby's heart rate decreasing by about 15 bpm" D. "The results of the test will be recorded as positive if no fetal movement occurs during the 20-minute testing period"
ANS: B. The fetal heart rate is considered healthy if the results are reactive. A reactive test indicates that there are fetal heart rate accelerations associated with fetal movement within the testing period. If the test is nonreactive, fetal health might be affected and further testing might be necessary to evaluate fetal well-being.
A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform first? A. Perform a detailed physical assessment B. Place the newborn directly on the client's chest C. Give the newborn IM vitamin K D. Administer erythromycin ophthalmic ointment
ANS: B. The greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature
A nurse in a clinic is assessing a client who is at 13 weeks gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority? A. Blood pressure 90/50 mmHg B. Ketones 2+ C. Specific gravity 1.035 D. Sodium 130 mEq/L
ANS: B. The greatest risk to this client is malnutrition which poses a serious risk to the developing fetus. Ketonuria indicates that the client's body is breaking down fat and protein stores for energy and cannot provide the fetus with essential nutrients. Therefore, this is the priority finding, and the nurse should report it to the provider immediately.
A nurse is reviewing recommended immunization with the guardian of a 2-month-old infant. Which of the following statements should the nurse make? A. "Your baby can receive the varicella vaccine at 6 months of age." B. "Your baby can start the pneumococcal vaccine now." C. "Your baby should receive the flu vaccine before 6 months of age." D. "Your baby can start the measles, mumps, and rubella vaccine now."
ANS: B. The infant can receive the first dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age. The nurse should instruct the guardian that the infant should not receive the varicella vaccine or the first dose of MMR vaccine until 1 year of age. The annual influenza vaccine begins at the age of 6 months.
A nurse in a prenatal clinic is reviewing the lab results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider? A. Hgb 11.3 g/dl B. Platelet count 135,000/mm^3 C. WBC count 10,500/mm^3 D. Hct 38%
ANS: B. The nurse should notify the provider of this result because it is an indication of thrombocytopenia. A low platelet count is a manifestation of preeclampsia or HELLP syndrome and requires further evaluation
A nurse is providing teaching about foods high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recommend? A. 1/2 cup whole milk B. 1/2 cup cooked pinto beans C. 1 cup green leaf lettuce D. 1 cup apple juice
ANS: B. The nurse should recommend foods high in fiber for a child who has chronic constipation. A half cup of cooked pinto beans contains approximately 5g of fiber. Therefore, the nurse should instruct the guardian to include this food in the child's diet. Whole milk, green leaf lettuce, and apple juice do not contain fiber
A nurse is reviewing the lab results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? A. 1.010 B. 1.035 C. 1.020 D. 1.005
ANS: B. This is a concentrated specific gravity, which is an expected value for a child who is dehydrated; therefore, this is an expected urine specific gravity for a child who has experienced diarrhea for 24 hr.
A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is. Which of the following responses should the nurse provide? A. "This test will determine if you are likely to deliver within the next week." B. "This test will help determine if your baby is healthy." C. "This test can see how your baby responds when you have contractions." D. "This test will determine if your baby's lungs are mature."
ANS: B.The NST is used as a prenatal fetal assessment. It tracks fetal heart rate patterns expected with fetal movement and can help identify fetal distress
A nurse is planning care for a preschooler who is scheduled for a surgical procedure. The nurse should identify that the preschooler is in which of the following of Erikson's psychosocial stages of development? A. Industry vs. inferiority B. Trust vs mistrust C. Initiative vs guilt D. Identity vs role confusio
ANS: C. A preshooler is the developmental stage of initiative vs guilt. Preschoolers initiate play activities and experience a feeling of guilt if their efforts at independence receive a negative reaction from caregivers. School-age is answer A. The child takes initiative for learning and doing things well. Support and positive reinforcement foster the school-age child's sense of pride, while a lack of appreciation can lead to a feeling of inferiority. Infant is answer B. A caregiver's response to the infant's needs builds trust and reassures the infant that his or her needs are being met. A caregiver who is inconsistent or rejecting can cause a feeling of mistrust. Adolescent is answer D. The adolescent combines his or her various roles and experiences into a personal identity. Failure to integrate these various images can lead to role confusion or uncertainty of identity or goal
A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine? A. Shellfish B. Gelatin C. Baker's yeast D. Eggs
ANS: C. An allergy to baker's yeast is a contraindication to receiving the hepatitis B vaccine. The nurse should notify the provider. Clients allergic to shellfish should not receive IV contrast dye, which contains iodine. Clients allergic to gelatin should not receive the MMR vaccine. Clients allergic to eggs should not receive the influenza vaccine.
A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following indicates the infant has moderate dehydration? A. Bulging anterior fontanel B. Bradycardia C. Tachypnea D. Polyuria
ANS: C. An infant who has moderate dehydration will have slight tachypnea. They will also have a flat or sunken fontanel, slightly increased heart rate, and decreased urinary output.
A nurse is assessing a client on the first postpartum day. Findings include the following: fundus firm and one fingerbreadth above the to the right of the umbilicus, moderate lochia rubra with small clots, temp 37.3C (99.2F), and pulse rate 52/min. Which of the following actions should the nurse take? A. Report the vital signs to the provider B. Massage the fundus C. Ask the client when she last voided. D. Administer an oxytocic agent
ANS: C. Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be firm at the midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void. The nurse should massage the fundus when it is boggy, not firm.
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as an indicator for further evaluation? A. The child prefers playmates of the same sex. B. The child is competitive when playing board games. C. The child complains daily about going to school . D. The child enjoys spending time alone
ANS: C. Complaining every day about going to school is an unexpected finding for a 7-year-old. The child is in Erikson's psychosocial development stage of industry vs. inferiority. Children at this stage want to learn and master new concepts. If the child complains daily about going to school, further evaluation is warranted
A nurse in an outpatient setting is providing education for a client who is pregnant. Which of the following statement should the nurse include in the teaching? A. "During the last trimester, you should sleep mainly on your back." B. "During the second trimester, you will notice increased urinary frequency and urgency." C. "You will probably first notice your baby moving when you are around 20 weeks gestation." D. "You should plan to gain 40 to 45 lbs during your pregnancy"
ANS: C. Fetal movement is typically noted by a pregnant client at 18 to 20 weeks gestation. Multiparous clients might notice the movement earlier. Clients should avoid a supine position during the latter half of pregnancy due to the risk of vena cava compression. Urinary frequency and urgency are common in the first and third trimesters but should be reported if present in the second trimester. The recommended weight gain during pregnancy is typically 25-30 lbs
A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? A. "Social services can contact various community resources that will be helpful." B. "I will review the care plan to make the necessary changes." C. "Let's set up a meeting time with the doctor to discuss your options for home care." D. "I will make a list of things we need to do before discharge.
ANS: C. In family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family members help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered nursing environment
A nurse is observing a mother who is playing peek-a-boo with her 8- month-old child. The mother asks if this game has any developmental significance. The nurse should reply that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination B. Sense of trust C. Object permanence D. Egocentrism
ANS: C. Object permanence refers to the cognitive skill of knowing an object still exists even when out of sight. By discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept
A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2cm, 50%, +1, right occiput ant3erior (ROA). Based on this info, which of the following fetal positions should the nurse document in the medical record? A. Transverse B. Breech C. Vertex D. Mentum
ANS: C. ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly on the client's right side. Based on the presentation of the fetus, the position is vertex. A transverse position indicates the fetus is lying horizontally in the pelvis and is presenting with a shoulder. Breech position indicates the fetus is upright in the uterus and is presenting its buttocks or feet. Mentum indicates that the fetus has fully extended the head and is presenting with its chin.
A nurse is assessing a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following conditions should the nurse screen the infant? A. Congenital heart disease B. Hearing loss C. Neurological disorder D. Amblyopia
ANS: C. The Moro reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn to startle him/her. A classic pattern of abduction and extension of the arms is expected. This reflex should be gone by 4 months of age; its presence after 4 months of age is associated with a neurological disorder.
A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? A. "I know not to eat anything after midnight." B. "I will have medication given to me to cause contractions." C. "I should press the button on the handheld marker when my baby moves." D. "I will have to stimulate my breast to cause contractions."
ANS: C. The client should press the button to help indicate when she feels fetal movement
A nurse is assessing a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus? A. 3 cm above the umbilicus B. 1 cm above the umbilicus C. 3 cm below the umbilicus D. 1 cm below the umbilicus
ANS: C. The client's fundus should descend about 1 to 2 cm every 24 hours; therefore, at 2 days postpartum, the client's fundus should be located 3 cm below the umbilicus.
A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn? A. 7 B. 8 C. 9 D. 10
ANS: C. The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 min and 5 min after birth. The nurs should assign a score of 0, 1, or 2 to every five categories. The nurse should assign a score of 2 for heart rate >100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well-being extremities, which shows normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and score of 1 for blue hands and feet, which is known as acrocyanosis
A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? A. Stepping B. Moro C. Rooting D. Babinski
ANS: C. The rooting reflex is elicited when the cheek is stroked and the newborn turns the head while making sucking motions with the mouth. This reflex supports effective sucking.
A nurse is assessing a 1-week old infant at a well-child visit. The nurse should notify the provider about which of the following assessment findings? A. A flat, dark pink area between the eyes that blanches B. An area of deep blue pigmentation over the buttocks C. A blue coloring of the sclera D. A patchy, red rash with raised centers
ANS: C. This discoloration is associated with osteogenesis imperfecta, a genetic disorder that results in bone fragility. The nurse should notify the provider of this finding.
A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. Slight thirst B. Cap refill of 3 seconds C. Deep, rapid respirations D. Decreased tear production
ANS: C. This finding is a manifestation of severe dehydration. Other manifestations include weight loss of >10%, parched mucus membranes, tachycardia, absence of tears or sunken eyeballs, intense thirst, and a cap refill of 4 seconds or greater with skin tenting. Slight thirst and cap refill of 3 seconds indicates mild dehydration. Cap refill of 3 seconds and decreased tear production indicate moderate dehydration
A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching? A. Mild constipation B. Nasal congestion C. Vaginal bleeding D 10 fetal movemnets per hour.
ANS: C. Vaginal bleeding can be an abnormal finding during pregnancy indicating a complication such as placental abruption, placenta previa, or preterm labor
A nurse is assessing a female client 24 hr after deliver and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take? A. Administer a tocolytic medication B. Apply a heating pad to the mid-abdominal area C. Reassess the fundus in 2 hr D. Ambulate the client to the bathroom
ANS: D. An increased fundal height in the postpartum period is a sign of a non-contracted uterus, which increases the risk of hemorrhage. The most common postpartum cause of an elevated fundal height is an overdistended bladder.
A nurse is caring for a client who is at 35 weeks gestation and is scheduled to undergo an amniocentesis. Which of the following statements should the nurse make? A. "You will have to drink 3 to 5 8-oz glasses of water to fill your bladder." B. "This procedure will not rupture your membranes or cause premature labor." C. "You might feel light pressure during the collection of a blood sample from the baby." D. "You will feel some mild discomfort during the procedure."
ANS: D. During amniocentesis, the client might feel slight uterine cramping when the needle comes into contact with the uterus. A local anesthetic is applied to the client's skin, so the client should not feel pain when the needle pierces the skin. The client should empty her bladder to reduce the risk of an accidental puncture during the procedure. Potential complications include preterm labor, leaking of amniotic fluid, fetal injury, and placental abruption. Amniocentesis involves withdrawing amniotic fluid, NOT blood, into a syringe. Some clients report a pulling sensation when the syringe is withdrawing the fluid.
A nurse is assessing a client who is suspected of having hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first? A. Complete blood count B. Liver enzymes C. Bilirubin level D. Urine ketones
ANS: D. Excessive ketones in the urine indicate the body is not using carbohydrates form food as fuel and is inadequately trying to break down fat. The presence of ketones in the urine supports the diagnosis of hyperemesis gravidarum.
A nurse is teaching a group of parents of toddlers about growth and development. A parent asks, "Why does my child's abdomen stick out?" Which of the following replies should the nurse provide? A. "You should give your child a stool softener daily." B. "Toddlers gain weight at a rapid pace." C. "You should have your child assessed for spinal deformity." D. "Toddlers do not have well-developed abdominal muscles."
ANS: D. The abdominal muscles are immature and minimally developed at this stage. Therefore, many toddlers have a "potbellied" appearance. Constipation is not the cause of the toddler's protruding abdomen. Toddlers are not growing as rapidly as they did in infancy, and weight gain does not cause a protruding abdomen. A spinal deformity is not generally the cause of a toddler's protruding abdomen.
A nurse is assessing a client who missed 2 menstrual cycles and reports that she might be pregnant. Which of the following findings is a positive sign of pregnancy? A. Quickening B. Breast tenderness C. Uterine enlargement D. Auscultation of a fetal heart rate
ANS: D. The auscultation of a fetal heart rate is a conclusive sign of pregnancy.
A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following response should the nurse provide? A. "Don't worry. Your baby is fine." B. "You will need to ask your provider about the monitor." C. "Your provider feels this step would be best." D. "We need to observe your baby more closely."
ANS: D. The client has asked an information-seeking question. This therapeutic response provides information in an honest, non-threatening manner. The use of an internal fetal scalp monitor or an internal spiral electrode provides a more accurate assessment of fetal well-being during labor.
A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first? A. Weigh the newborn B. Instill erythromycin ophthalmic ointment in the newborn's eyes C. Administer vitamin K to the newborn D. Dry the newborn
ANS: D. The greatest risk to the newborn immediately after birth is heat loss, which can cause cold stress, respiratory distress, and hypoglycemic. Therefore, the first action the nurse should take is to dry the newborn to prevent heat loss from evaporation
A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? A. Administer vitamin K subcutaneously B. Administer erythromycin eye ointment within 12 hours C. Administer erythromycin eye ointment from the outer canthus toward the inner canthus D. Administer vitamin K in the newborn's thigh
ANS: D. The nurse should administer vitamin K to the vastus lateralis muscle in the newborn's thigh. Erythromycin eye ointment should be administered within 1-2 hours after birth and can be administered after the initial breastfeeding. Administer the erythromycin ointment starting at the inner canthus toward the outer canthus.
A nurse is assessing a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect? A. Elevated serum potassium level B. Rapid weight gain C. Peripheral edema D. Presence of ketones in the urine
ANS: D. The nurse should expect a client who has hyperemesis gravidarum to have ketonuria due to an inadequate dietary intake, resulting in the breakdown of protein and stored fate. Other signs and symptoms of hyperemesis gravidarum are hypokalemia and weight loss due to nausea, vomiting, and dehydration.
