Exam 2

Meningicoccal (MCV)

11 y.o

Tdap

11 y.o

Human Papilomavirus (HPV)

11 y.o, 2nd dose given 2 months after 1st dose, 3rd dose given 6 months after 1st dose

Hepatitis A

12 months, 2nd dose given 6 months after 1st dose

Measles, mumps, rubella (MMR)

12 months, 4 y.o

Varicella

12 months, 4 y.o.

Rotavirus

2 months, 4 months, 6 months Dont start if over 15 weeks

Haemophilus influenzae type B (Hib)

2 mos, 4 mos, 6 mos, 12 mos, 4 y.o

Pneumococcal (PCV)

2 mos, 4 mos, 6 mos, 12 mos, 4 y.o.

DTaP

2 mos, 4 mos, 6 mos, 12 mos, 4, y.o.

Inactivated polio virus (IPV)

2 mos, 4 mos, 6 mos, 4 y.o.

What clinical manifestations would the nurse expect to find in a newborn who has developed necrotizing enterocolitis (NEC)? 1. Hyperthermia 2. Gastric residual and melena 3. The passage of ribbon-like stools 4. Projectile vomiting

2. Gastric residual and melena

RN is conducting a home visit for a client who's 1 wk postpartum & breastfeeding. The client reports breast engorgement. Which of the following recommendations should the RN make? A. "Apply cold compresses between feedings" B. "Take a warm shower right after feedings" C. "Apply breast milk to the nipples & allow them to air dry" D. "Use various infant positions for feedings"

A. "Apply cold compresses between feedings"

RN is providing discharge teaching for a nonlactating client. Which of the following instructions should the RN include in the teaching? A. "Wear a supportive bra continuously for the first 72 hrs" B. "Pump your breast q4h to relieve discomfort" C. "Use breast shells throughout the day to decrease milk supply" D. "Apply warm compresses until milk suppression occurs"

A. "Wear a supportive bra continuously for the first 72 hrs"

RN is caring for a child who has Meckel's diverticulum. Which of the following manifestations should the RN expect? (Select all that apply) A. Abdominal pain B. Fever C. Mucus, bloody stools D. Vomiting E. Rapid, shallow breathing

A. Abdominal pain C. Mucus, bloody stools

RN is caring for a client who's in labor & observes late decelerations on electronic fetal monitor. Which of the following is the first action the RN should take? A. Assist client into left-lateral position B. Apply fetal scalp electrode C. Insert an IV catheter D. Perform a vaginal exam

A. Assist client into left-lateral position

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? A. Bright red, raised bumpy area noted above the right eye B. Small pink of red patches on the baby's eyelids, and back of the neck C. Fine red rash noted over the chest and back D. Blue or purplish splotches on buttocks.

A. Bright red, raised bumpy area noted above the right eye

RN is caring for a client who's 1 hr postpartum following a vaginal birth & experiencing uncontrollable shaking. The RN should understand that the shaking is d/t which of the following factors? (Select all that apply) A. Change in body fluids B. Metabolic effort of labor C. Diaphoresis D. Decrease in body temp E. Decrease in prolactin levels

A. Change in body fluids B. Metabolic effort of labor

A nurse is providing teaching to the parent of a child who is to have an electroencephalogram (EEG). Which of the following responses should the nurse include in the teaching? a. decaffeinated beverages should be offered on the morning of the procedure b. do not wash your child's hair the night before the procedure c. withhold all foods the morning of the procedure d. give your child an analgesic the night before the procedure

A. Decaffeinated beverages should be offered on the morning of the procedure

RN is caring for a client who's 1 day postpartum. RN is assessing for maternal adaptation & mother-infant bonding. Which of the following behaviors by the client indicates a need for the RN to intervene? (Select all that apply) A. Demonstrates apathy when the infant cries B. Touches the infant & maintains close physical proximity C. View the infant's behavior as uncooperative during diaper changing D. Identifies & relates infant's characteristics to those of family members E. Interprets the infant's behavior as meaningful & a way of expressing feelings

A. Demonstrates apathy when the infant cries C. View the infant's behavior as uncooperative during diaper changing

RN is caring for a client who's 40 wks gestation & experiencing contractions q3-5m & becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, & -1 station. The client asks for pain medication. Which of the following actions should the RN take? Select all that apply. A. Encourage use of patterned breathing techniques B. Insert indwelling urinary catheter C. Administer opioid analgesic medication D. Suggest application of cold E. Provide ice chips

A. Encourage use of patterned breathing techniques C. Administer opioid analgesic medication D. Suggest application of cold

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? A. Expose the newborn's bottom to air several times a day. B. Use only baby wipes to cleanse the perianal area. C. Use products such as talcum powder with each diaper change. D. Place the newborn's buttocks in warm water after each void or stool.

A. Expose the newborn's bottom to air several times a day.

RN is assessing a child who has a rotavirus infection. Which of the following are expected findings? (Select all that apply) A. Fever B. Vomiting C. Watery stools D. Bloody stools E. Confusion

A. Fever B. Vomiting C. Watery stools

RN in L&D unit is caring for a client in labor & applies an external fetal monitor & tocotransducer. The FHR is ~140 bpm. Contractions are occurring q8m & 30-40 seconds in duration. RN performs a vaginal exam & finds the cervix 2 cm dilated, 50% effaced & fetus is a -2 station. Which of the following stages & phases of labor is the client experiencing? 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

RN is educating the mother of a newborn about feeding and burping. Which strategy should the nurse offer to the mother regarding burping? A. Hold the newborn upright with the newborn's head on the mother's shoulder. B. Lay the newborn on its back on its mothers lap. C. Gently rub the newborn's abdomen while the newborn is in a sitting position. D. Lay the newborn on its abdomen in the mothers lap and gently pat the buttocks.

A. Hold the newborn upright with the newborn's head on the mother's shoulder.

RN is planning to administer recommended immunizations to a 4 y.o. child. Which of the following vaccines should the nurse plan to give? (Select all that apply) A. IPV B. Hib C. MMR D. VAR E. HepB F.. DTaP

A. IPV C. MMR D. VAR F.. DTaP

RN is explaining the benefits of breastfeeding to a client who has just delivered. Which statement correctly explains the benefits of breastfeeding to this mother? A. Immunoglobulin IgA in breast milk boosts a newborn's immune system. B. Breast feeding provides more iron and calcium for infant C. Mothers who breast feed have increased breast size following nursing D. Breast fed infants gain weight faster than formula-fed infants after 6 months of age.

A. Immunoglobulin IgA in breast milk boosts a newborn's immune system.

A nurse who has been caring for a pregnant client understands that the client has pica and has been regularly consuming soil. For which condition should the nurse monitor the client? A. Iron-deficiency anemia B. Constipation C. Tooth fracture D. Inefficient protein metabolism

A. Iron-deficiency anemia

RN is admitting a child who has severely symptomatic HIV. Which of the following findings should the nurse expect? (Select all that apply) A. Kaposi's sarcoma B. Hepatitis C. Wasting syndrome D. Pulmonary candidiasis E. Cardiomyopathy

A. Kaposi's sarcoma C. Wasting syndrome D. Pulmonary candidiasis

RN is caring for a client in the 3rd stage of labor. Which of the following findings indicate that placental separation? Select all that apply. A. Lengthening of the umbilical cord B. Swift gush of clear amniotic fluid C. Softening of the lower uterine segment D. Appearance of dark blood from the vagina E. Fundus firm upon palpation

A. Lengthening of the umbilical cord D. Appearance of dark blood from the vagina E. Fundus firm upon palpation

RN is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply. A. Lethargy B. Low pitched cry C. Cyanosis D. Skin rashes E. Jitteriness

A. Lethargy C. Cyanosis E. Jitteriness

Which factors could increase the risk of overheating in a newborn? Select all that apply. A. Limited ability of diaphoresis B. Underdeveloped lungs C. Isolette that is too warm D. Limited sugar stores E. Lack of brown fat

A. Limited ability of diaphoresis C. Isolette that is too warm

RN is performing fundal assessment for client who's 2 days postpartum & observes the perineal pad for lochia. She notes the pad to be saturated ~12 cm with lochia that is bright red & contains small clots. Which of the following findings should the RN document? A. Moderate lochia rubra B. Excessive blood loss C. Light lochia rubra D. Scant lochia serosa

A. Moderate lochia rubra

RN is providing care for a client in active labor. Her cervix is dilated to 5 cm, membranes are intact. Based on the use of external electronic fetal monitoring, the RN notes a FHR of 115-125 bpm w/ occasional increases up to 150-155 bpm that last for 25 seconds & have beat-to-beat variability of 20 bpm. There's no slowing of FHR from baseline. RN should recognize that client is exhibiting signs of which of the following? Select all that apply. A. Moderate variability B. FHR accelerations C. FHR decelerations D. Normal baseline FHR E. Fetal tachycardia

A. Moderate variability B. FHR accelerations D. Normal baseline FHR

RN is performing a detailed newborn assessment of a female newborn. Which observations indicate a normal finding? Select all that apply A. Mongolian spots. B. Enlarged fontanels C. Swollen genitals D. Low set ears E. Short creased neck.

A. Mongolian spots. C. Swollen genitals E. Short creased neck.

RN is teaching a parent of a child who has HIV. Which of the following information should the nurse include? (Select all that apply) A. Obtain yearly influenza vaccination. B. Monitor a fever for 24 hr before seeking medical care. C. Avoid individuals who have colds. D. Provide nutritional supplements. E. Administer aspirin for pain.

A. Obtain yearly influenza vaccination. C. Avoid individuals who have colds. D. Provide nutritional supplements.

RN is teaching a parent of an infant about GI reflux disease. Which of the following should the RN include in the teaching? (Select all that apply) A. Offer frequent feedings B. Thicken formula with rice cereal C. Use a bottle with a one-way valve D. Position baby upright after feedings E. Use a wide-based nipple for feeding

A. Offer frequent feedings B. Thicken formula with rice cereal D. Position baby upright after feedings

RN is caring for a child who's suspected to have Enterobius vermicularis. Which of the following actions should the RN take? A. Perform a tape test B. Collect stool specimen for culture C. Test stool for occult blood D. Initiate IV fluids

A. Perform a tape test

RN is assessing an infant who has hypertrophic pyloric stenosis. Which of the following findings would the RN expect? (Select all that apply) A. Projectile vomiting B. Dry mucus membranes C. Currant jelly stools D. Sausage-shaped abdominal mass E. Constant hunger

A. Projectile vomiting B. Dry mucus membranes E. Constant hunger

RN wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met? A. Promote early breast feeding for the infants B. Avoid skin to skin contact with the mother until the infants are 8 hours old C. Keep the infant transporter temp between 80 and 85 degrees F D. Avoid bathing the newborn until they are 24 hours old.

A. Promote early breast feeding for the infants

RN is caring for a client who's in the second stage of labor. Client's labor has been progressing & she's expecting to deliver vaginally in 20 minutes. The provider is preparing to administer lidocaine for pain relief & perform an episiotomy. The RN should know which of the following types of regional anesthetic block is to be administered? A. Pudendal B. Epidural C. Spinal D. Paracervical

A. Pudendal

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next? A. Respiratory rate B. Temp C. Pulse C. Uterine contractions

A. Respiratory rate

RN is planning to administer recommended immunizations to a 2 m.o. Which of the following vaccines should the nurse plan to give? ( Select all that apply) A. Rotavirus B. DTaP C. Hib D. HepA E. PCV13 F. IPV

A. Rotavirus B. DTaP C. Hib E. PCV13 F. IPV

RN is assessing a client who has pertussis. Which of the following findings should the nurse expect? (Select all that apply) A. Runny nose B. Mild fever C. Cough with whopping sound D. Swollen salivary glands E. Red Rash

A. Runny nose B. Mild fever C. Cough with whopping sound

RN is caring for a 10 y/o who has nephrotic syndrome. Which of the following findings should the RN report to the provider? A. Serum protein 5.0 g/dL B. Hgb 14.5 g/ dL C. Hct 40% D. Platelet 200,000 mm3

A. Serum protein 5.0 g/dL

RN is teaching a group of parents about E. coli. Which of the following information should the RN include in the teaching? (Select all that apply) A. Severe abdominal cramping occurs B. Watery diarrhea is present for more than 5 days C. It can lead to hemolytic uremic syndrome D. Foodborne pathogen E. Antibiotics are given for Tx

A. Severe abdominal cramping occurs C. It can lead to hemolytic uremic syndrome D. Foodborne pathogen

A mother who is 4 days postpartum, and is breast feeding , expresses to the nurse that her breast seems to be tender and engorged. What education should the nurse give to the mother to relieve breast engorgement? Select all that apply. A. Take warm to hot showers to encourage milk release B. Feed the newborn in the sitting position only C. Express some milk manually before breast feeding. D. Massage the breasts from the nipple toward the axillary area. E. Apply warm compresses to the breasts prior to nursing.

A. Take warm to hot showers to encourage milk release C. Express some milk manually before breast feeding. E. Apply warm compresses to the breasts prior to nursing.

A client delivers a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings? A. The infant is entering the habituation state. B. The infant is attempting self consoling maneuvers. C. The infant is in a state of hyperactivity. D. The infant is displaying a state of alertness.

A. The infant is entering the habituation state.

A first time mother informs the nurse that she is unable to breast feed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? A. Use the sealed and chilled milk within 24 hrs. B. Use any frozen milk within 6 months of obtaining it. C. Use microwave ovens to warm the chilled milk. D. Refreeze any unused milk for later use if it has not been out more than 2 hours.

A. Use the sealed and chilled milk within 24 hrs.

RN is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment? A. Yellow sclera B. Abdominal distention C. HR of 130 beats/min D. Respiratory rate of 24

A. Yellow sclera

A nurse is assessing a child who has a concussion. Which of the following findings should the nurse expect? (select all that apply) a. amnesia b. systemic hypertension c. bradycardia d. respiratory depression e. confusion

A. amnesia C. bradycardia D. respiratory depression E. confusion

A 2-month-old breastfed infant is successfully rehydrated with oral rehydration solutions (ORSs) for acute diarrhea. Instructions to the mother about breastfeeding should include to A. continue breastfeeding. b. stop breastfeeding until breast milk is cultured. c. stop breastfeeding until diarrhea is absent for 24 hours. d. express breast milk and dilute with sterile water before feeding.

A. continue breastfeeding.

A nurse is teaching a group of parents about the risk factors for seizures. Which of the following factors should the nurse include in the teaching? (select all that apply) a. febrile episodes b. hypoglycemia c. sodium imbalances d. low serum lead levels e. presence of diphtheria

A. febrile episodes B. hypoglycemia C. sodium imbalances

A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (select all that apply) a. loss of consciousness b. appearance of daydreaming c. dropping held objects d. falling to the floor e. having a piercing cry

A. loss of consciousness C. dropping held objects

A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? a. maintain the child in a side-lying position b. loosen the child's restrictive clothing c. reorient the child to the environment d. note the time and characteristics of the child's seizure

A. maintain the child in a side-lying position

A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings should the nurse identify as indicating viral meningitis? (select all that apply) a. negative gram stain b. normal glucose content c. cloudy color d. decreased WBC count e. normal protein content

A. negative gram stain B. normal glucose content E. normal protein content

A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions by the nurse is appropriate? a. place the clint on NPO status b. prepare the client for a liver biopsy c. position the client dorsal recumbent d. put the client in a protective environment

A. place the client on NPO status

A nurse is providing teaching about epistaxis to the parent of a school-age child. Which of the following should the nurse include as an appropriate action to take when managing an episode of epistaxis? (select all that apply) a. press the nares together for at least 10 min. b. breathe through the nose until bleeding stops c. pack cotton or tissue into the naris that is bleeding d. apply a warm cloth across the bridge of the nose e. insert petroleum into the naris after the bleeding stops

A. press the nares together for at least 10 min. C. pack cotton or tissue into the nares that is bleeding

A nurse often cares for children who are dying. Which of the following are appropriate actions for the nurse to take to maintain professional effectiveness? (select all that apply) a. remain in contact with the family after their loss b. develop a professional support system c. take time off from work d. suggest that a hospital representative attend the funeral e. demonstrate feelings of sympathy toward the family

A. remain in contact with the family after their loss B. develop a professional support system C. take time off of work

A nurse is caring for an adolescent who has a closed head injury. Which of the following findings are indications of increased intracranial pressure (ICP)? (select all that apply) a. report of headache b. alteration in pupillary response c. increased motor response d. increased sleeping e. increased sensory response

A. report of headache B. alteration in pupillary response D. increased sleeping

A nurse is providing teaching about the management of epistaxis to a child and his family. Which of the following positions should the nurse instruct the child to take when experiencing a nosebleed? a. sit up and lean forward b. sit up and tilt the head up c. lie in a supine position d. lie in a prone position

A. sit up and lean forward

A nurse is in the emergency department is assessing a child following a motor-vehicle crash. The child is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following actions should the nurse take first? a. stabilize the child's neck b. clean the child's laceration with soap and water c. implement seizure precautions for the child d. initiate IV access for the child

A. stabilize the child's neck

Which statement best describes Hirschsprung disease? A. The colon has an aganglionic segment. B. There is a passage of excessive amounts of meconium in the neonate. C. It results in excessive peristaltic movements within the gastrointestinal tract. D. It results in frequent evacuation of solids, liquids, and gas.

A. the colon has an aganglionic segment

A nurse is reviewing treatment options with the parent of a child who has worsening seizures. Which of the following treatment options should the nurse include in the discussion? (select all that apply) a. vagal nerve stimulator b. additional anti epileptic medications c. corpus collosotomy d. focal resection e. radiation therapy

A. vagal nerve stimulator B. additional anti-epileptic medications C. corpus collostomy D. focal resection

RN is completing postpartum discharge teaching to a client who had no immunity to varicella & was given varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? A. "I'll need to use contraception for 3 months before considering pregnancy" B. "I need a second vaccination at my postpartum visit" C. "I was given the vaccine because my baby is O-positive" D. "I'll be testing in 3 months to see if I've developed immunity"

B. "I need a second vaccination at my postpartum visit"

RN is teaching a client about benefits of internal fetal heart monitoring. Which of the following statements should the RN include in the teaching? Select all that apply. A. "It's considered a noninvasive procedure" B. "It can detect abnormal fetal heart tones early" C. "It can determine the amount of amniotic fluid you have" D. "It allows for accurate readings with maternal movement" E. "It can measure uterine contraction intensity"

B. "It can detect abnormal fetal heart tones early" D. "It allows for accurate readings with maternal movement" E. "It can measure uterine contraction intensity"

RN is caring for a client who's 2 days postpartum. The client states, "my 4 y/o son was trained & now he's frequently wetting himself". Which of the following statements should the RN provide to the client? A. "Your son was probably not ready for toilet training & should wear training pants" B. "Your son is showing an adverse sibling response" C. "Your son may need counseling" D. "You should try sending your son to preschool to resolve the behavior"

B. "Your son is showing an adverse sibling response"

The mother of a formula fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? A. Your newborn should finish a bottle in less than 15 mins B. A sign of normal nutrition is when your newborn seems satisfied and gaining sufficient weight. C. If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed. D. Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding.

B. A sign of normal nutrition is when your newborn seems satisfied and gaining sufficient weight.

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor? A. Monitor VS B. Assess amounts of cervical dilation C. Obtain urine specimen for urinalysis D. Monitor hydration status

B. Assess amounts of cervical dilation

RN in a outpatient facility is caring for an infant who has manifestations of acute otitis media. Which of the following factors places the infant at risk for otitis media? (Select all that apply) A. Breastfeeding without formula supplementation B. Attends daycare 4 days per week C. Immunizations are up to date D. History of cleft palate repair E. Parents smoke cigarettes outside.

B. Attends daycare 4 days per week D. History of cleft palate repair E. Parents smoke cigarettes outside.

RN is teaching a parent of a child who has a UTI. Which of the following should the RN include in the teaching? (Select all that apply) A. Wear nylon underpants B. Avoid bubble baths C. Empty bladder completely w/ each void D. Provide information about manifestations of infection E. Wipe perineal area back to front

B. Avoid bubble baths C. Empty bladder completely w/ each void D. Provide information about manifestations of infection

RN is providing care for a client who's diagnosed with a marginal abruptio placentae. The RN is aware that which of the following are risk factors for developing the condition? Select all that apply. A. Fetal position B. Blunt abdominal trauma C. Cocaine use D. Maternal age E. Cigarette smoking

B. Blunt abdominal trauma C. Cocaine use E. Cigarette smoking

A breast feeding mother wants to know how to help her 2 week old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? A. The mother pump her breast milk and measure it before feeding. B. Breast feed the infant every 2-3 hrs on demand C. Weigh the infant daily to ensure that she is gaining 1.5-2 oz per day. D. Add cereal to the newborn's feedings twice a day.

B. Breast feed the infant every 2-3 hrs on demand

A primiparous mother delivered a 8 lb 12 oz infant daughter yesterday. She is being bottle fed, Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice? A. Formula feeding B. Cephalohematoma C. Female gender D. Hepatitis A vaccine E. Rh positive blood type

B. Cephalohematoma

RN is providing care to 4 clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A. Client who has an episiotomy that's erythematous & has extended into a 3rd degree laceration B. Client who doesn't wash her hands between perineal care & breastfeeding C. Client who's not breastfeeding & using measures to suppress lactation D. Client who has a c-section incision that's well-approximated w/ no drainage

B. Client who doesn't wash her hands between perineal care & breastfeeding

You are educating nursing student regarding fluid requirements for pediatric patients who present with comorbidities. Increased need for fluid requirements would be consistent with treatment management for which conditions? (Select all that apply.) a. Congestive Heart Failure (CHF) d. Diabetes ketoacidosis c. Syndrome of inappropriate diuretic hormone (SIADH) d. Diabetes Insipidus(DI) Correct e. Burn

B. Diabetes ketoacidosis d. Diabetes Insipidus(DI) E. Burns

RN is providing teaching for an adolescent client who has mono. The client has a fever, fatigue, swollen lymph nodes, sore throat, and a sore upper abdomen. Which of the following instructions should the nurse include in the teaching? (Select all that apply) A. Take antibiotics until symptoms subside. B. Drink plenty of liquids C. Avoid participating in strenuous activities D. Allow for periods of rest E. Take aspirin as needed for fever and discomfort F. Gargle with saltwater every 2-3 hr

B. Drink plenty of liquids C. Avoid participating in strenuous activities D. Allow for periods of rest E. Take aspirin as needed for fever and discomfort F. Gargle with saltwater every 2-3 hr

RN is assessing a child who has nephrotic syndrome. Which of the following findings should the RN expect? Select all that apply. A. Dipstick protein of 1+ B. Edema in the ankles C. Hyperlipidemia D. Weight loss E. Anorexia

B. Edema in the ankles C. Hyperlipidemia E. Anorexia

RN is caring for a child who has enuresis. Which of the following is a complication of enuresis? A. UTIs B. Emotional problems C. Urosepsis D. Progressive kidney disease

B. Emotional problems

A client in the early postpartum period is very excited & talkative. She's repeatedly telling the RN every detail of her labor & birth. Because the client will not stop talking, the RN is having difficulty completing the postpartum assessments. Which of the following actions should the RN take? A. Come back later when the client is more cooperative B. Give the client time to express her feelings C. Tell the client she needs to be quiet so assessment can be completed D. Redirect the client's focus so that she will become quiet

B. Give the client time to express her feelings

RN is teaching a group of adolescents about HIV/AIDs. Which of the following statements should the nurse include in the teaching? A. You can contract HIV through casual kissing. B. HIV is transmitted through IV substance use. C. HIV is now curable if caught in the early stages. D. Medications inhibit transmission of the HIV virus.

B. HIV is transmitted through IV substance use.

RN in L&D unit is completing an admission assessment for a client who's at 39 wks gestation. Client reports that she's been leaking fluid from her vagina for 2 days. Which of the following conditions is the client at risk for developing? A. Cord prolapse B. Infection C. Postpartum hemorrhage D. Hydramnios

B. Infection

RN is caring for a child who has had watery diarrhea for the past 3 days. Which of the following is an appropriate action for the RN to take? A. Offer chicken broth B. Initiate oral rehydration therapy C. Start hypertonic IV solution D. Keep NPO until diarrhea subsides

B. Initiate oral rehydration therapy

RN is assessing an infant who has a suspected UTI. Which of the following are anticipated findings? (Select all that apply) A. Increase in hunger B. Irritability C. Decrease in urination D. Vomiting E. Fever

B. Irritability D. Vomiting E. Fever

RN is teaching a group of parents about Salmonella. Which of the following information should the RN include in the teaching? (Select all that apply) A. Incubation period is nonspecific B. It's a bacterial infection C. Blood diarrhea is common D. Transmission can be from house pets E. Antibiotics are used for treatment

B. It's a bacterial infection C. Blood diarrhea is common D. Transmission can be from house pets

A client delivers a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home? A. Ensure cool air is circulating over the newborn to prevent overheating. B. Keep the newborn wrapped in a blanket with a cap on its head. C. Encourage the mother to keep the infant in her bed to ensure that the infant stays warm. D. Keep the infant's room at least 80 degrees.

B. Keep the newborn wrapped in a blanket with a cap on its head.

Client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. Which of the following actions should the RN take first? A. Check the amniotic fluid for meconium B. Monitor FHR for distress C. Dry the client & make her comfortable D. Monitor for uterine contractions

B. Monitor FHR for distress

A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula fed. What instruction should the nurse give this client? A. Switch to feeding breast milk. B. No action is needed; this is normal C. Increase the newborn's fluid intake D. Change to a soy-based formula.

B. No action is needed; this is normal

RN is performing Leopold maneuvers on a client who's in labor. Which of the following techniques should the RN use to identify the fetal lie? A. Apply palms of both hands to sides of uterus B. Palpate the fundus of the uterus C. Grasp lower uterine segment between thumb & fingers D. Stand facing client's feet w/ fingertips outlining cephalic prominence

B. Palpate the fundus of the uterus

RN is caring for a child who has poststreptococcal glomerulonephritis (APSGN). Which of the following manifestations should the RN expect? Select all that apply. A. Frothy urine B. Periorbital edema C. Ill appearance D. Decreased creatinine E. HTN

B. Periorbital edema C. Ill appearance E. HTN

RN is caring for an infant who's postop following cleft lip & palate repair. Which of the following actions should the RN take? A. Remove the packing in the mouth B. Place the infant in an upright position C. Offer a pacifier with sucrose D. Assess the mouth with a tongue blade

B. Place the infant in an upright position

RN is caring for a client who's in the transition phase of labor & reports that she needs to have a BM with the peak of contractions. Which of the following actions should the RN make? A. Assist the client to the bathroom B. Prepare for an impending delivery C. Prepare to remove a fecal impaction D. Encourage the client to take deep, cleansing breaths

B. Prepare for an impending delivery

RN is caring for a child who has Hirschsprung's disease. Which of the following actions should the RN take? A. Encourage high fiber, low protein, low calorie diet B. Prepare the family for surgery C. Place an NG tube for decompression D. Initiate bed rest

B. Prepare the family for surgery

RN is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. A. Provide warm water to drink B. Provide oxygen supplementation C. Massage the newborn's back. D. Ensure the newborn's warmth E. Observe respiratory status frequently.

B. Provide oxygen supplementation D. Ensure the newborn's warmth E. Observe respiratory status frequently.

RN is assessing an infant. Which of the following findings are clinical manifestations of acute otitis media? (Select all that apply) A. Decreased pain in supine position B. Rolling head side to side C. Loss of appetite D. Increased sensitivity to sound E. Crying

B. Rolling head side to side C. Loss of appetite E. Crying

RN is teaching a group of parents about complications of communicable diseases. Which of the following communicable diseases can lead to pneumonia? Select all that apply A. Rubella B. Rubeola C. Pertussis D. Varicella E. Mumps

B. Rubeola C. Pertussis D. Varicella

RN is caring for a client who's in active labor. Client reports lower back pain. RN suspects this is r/t persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the RN recommend? A. Abdominal effleurage B. Sacral counterpressure C. Showering if not contraindicated D. Back rub & massage

B. Sacral counterpressure

RN is caring for a 10 y/o child who has acute glomerulonephritis. Which of the following findings should the RN report to the provider? A. Serum BUN 8 mg/ dL B. Serum CREA 1.3 mg/ dL C. BP 100/74 mm Hg D. Urine output 550 ml in 24 hours

B. Serum CREA 1.3 mg/ dL

RN is assessing a child who has a UTI. Which of the following are manifestations of a UTI? Select all that apply. A. Night sweats B. Swelling of the face C. Pallor D. Pale-colored urine E. Fatigue

B. Swelling of the face C. Pallor E. Fatigue

When caring for a newborn, the nurse observes that the neonate has developed white patches on the mucus membranes of the mouth. Which condition is the newborn most likely experiencing? A. Rubella B. Thrush C. Cytomegalovirus infection D. Toxoplasmosis

B. Thrush

RN is assessing a postpartum client for fundal height, location & consistency. The fundus is noted to be displaced laterally to the right & there's uterine atony. The RN should identify which of the following conditions as the cause for uterine atony. A. Poor involution B. Urinary retention C. Hemorrhage D. Infection

B. Urinary retention

RN is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's labs. Which of the following findings is a manifestation of this condition? A. Hgb 12.2 g/dL B. Urine ketones present C. ALT 20 IU/L D. Serum glucose 114 mg/ dL

B. Urine ketones present

RN caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? A. Within 30 mins after birth, in the birthing area. B. Within the first 2-4 hrs, when the newborn reaches the nursery. C. Prior the newborn being discharged D. 24 hours after the newborn's birth.

B. Within the first 2-4 hrs, when the newborn reaches the nursery.

RN is caring for a toddler who has rhinitis, cough, and diarrhea for 2 days. Upon assessment, it is noted that the tympanic membrane has an orange discoloration and decreased movement. Which of the following statements should the nurse make? A. Your child has an ear infection that requires antibiotics B. Your child could experience transient hearing loss C. Your child will need to be on a decongestant until this clears. D. Your child will need to have a myringotomy.

B. Your child could experience transient hearing loss

A 4-year-old child has ingested a toxic dose of iron. The parent reports that the child vomited and complained of gastric pain an hour ago but "feels fine" now. The parent is not certain when the child ingested the iron tablets. The most appropriate recommendation by the nurse to the parent is to A. observe the child closely for 2 more hours. B. bring the child to the hospital immediately. C. administer activated charcoal. D. administer ipecac to induce vomiting if the child does not vomit again within 1 hour.

B. bring child to the hospital immediately

A nurse is caring for an infant whose screening test reveals that he might have sickle cell disease. Which of the following tests should be performed to distinguish if the infant has the trait or the disease? a. sickle solubility test b. hemoglobin electrophoresis c. complete blood count d. transcranial doppler

B. hemoglobin electrophoresis

A nurse is caring for a child who has ICP. Which of the following actions should the nurse take? (select all that apply) a. suction the endotracheal tube every 2 hours b. maintain a quiet environment c. use two pillows to elevate the head d. administer a stool softener e. maintain body alignment

B. maintain a quiet environment D. administer a stool softener E. maintain body alignment

a nurse is teaching a parent about complicated grief. Which of the following statements should the nurse make? a. it is considered complicated grief if you are still grieving 6 months after your loss b. personal activities are affected when experiencing complicated grief c. parents will experience complicated grief together d. complicated grief self-resolves in 12 months

B. personal activities are affected when experiencing complicated grief

A nurse is developing an in service about viral and bacterial meningitis. The nurse should include the the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (select all that apply) a. inactivated polio vaccine (IPV) b. Pneumococcal conjugate vaccine (PCV) c. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) d. Haemophilus influenzae type B (Hib) vaccine e. Trivalent inactivated influenza vaccine (TIV)

B. pneumococcal conjugate vaccine (PCV) D. haemophilus influenzae type B (Hib) vaccine

a nurse is teaching a parent of a preschool child about factors that affect the child's perception of death. Which of the following factors should the nurse include in the teaching? a. preschool children have no concept of death b. preschool children perceive death as temporary c. preschool children often regress to an earlier stage of behavior d. preschool children experience fear related to the disease process

B. preschool children perceive death as temporary

A nurse is preparing to administer iron dextran Im to a school age child who has iron deficiency anemia. Which of the following actions by the nurse is appropriate? a. administer the dose in the deltoid muscle b. use the Z track method when administering the dose c. avoid injecting more than 2 mL with each dose d. Massage the injection site for 1 min after administering the dose

B. use the Z track method when administering the dose

Flu

Begin annual flu vaccine at 6 months. Will need 2 shots 4 weeks apart if first time getting flu shot.

Hepatitis B vaccine

Birth, 1 month, 6 months

RN is caring for a client following the administration of an epidural block & preparing to administer IV bolus. Client's partner asks about the purpose of IV fluids. Which of the following is an appropriate response for the RN to make? A. "It's needed to promote increased urine output" B. "It's needed to counteract respiratory depression" C. "It's needed to counteract hypotension" D. "It's needed to prevent oligohydramnios"

C. "It's needed to counteract hypotension"

RN is caring for client & partner during the 2nd stage of labor. Client's partner asks the RN to explain how he'll know when crowning occurs. Which of the following responses should the RN make? A. "The placenta will protrude from the vagina" B. "Your partner will report a decrease in the intensity of the contractions" C. "The vaginal area will bulge as the baby's head appears" D. "Your partner will report less rectal pressure"

C. "The vaginal area will bulge as the baby's head appears"

What is an advantage to teach to the family about continuous cycling peritoneal dialysis (CCPD) or continuous ambulatory peritoneal dialysis (CAPD) for adolescents who require dialysis? a. Hospitalization is only required several nights per week. b. Dietary restrictions are no longer necessary. c. Adolescents can carry out procedures themselves. d. Insertion of a catheter does not require surgical placement.

C. Adolescents can carry out procedures themselves.

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? A. Shivering B. Hyperglycemia C. Apnea D. Metabolic alkalosis

C. Apnea

RN is preparing to administer the varicella vaccine to an adolescent. Which of the following questions should the nurse ask to determine whether there is a contradiction to adminstering the vaccine? A. Do you have an allergy to eggs? B. Have you ever had encephalopathy following immunizations? C. Are you currently taking corticosteroid meds? D. Have you ever had an anaphylactic reaction to yeast?

C. Are you currently taking corticosteroid meds?

A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solution (ORS). The child's mother calls the clinic nurse because the child is also occasionally vomiting. What should the nurse recommend? A. Bring the child to the hospital for intravenous fluids. B. Alternate giving ORS and carbonated drinks. C. Continue to give ORS frequently in small amounts. D. Institute a nothing by mouth (NPO) status for the child for 8 hours, and resume ORS if vomiting has subsided.

C. Continue to give ORS frequently in small amounts.

What should the nurse include when teaching an adolescent with Crohn disease? a.Preventing the spread of illness to others and nutritional guidance b Adjusting to chronic illness and preventing the spread of illness to others c. Coping with stress and adjusting to chronic illness d. Nutritional guidance and preventing constipation

C. Coping with stress and adjusting to chronic illness

RN is admitting a child who has HIV. The nurse should identify which of the following findings as an indication that the child is in the mildly symptomatic category of HIV? (Select all that apply) A. Herpes zoster B. Anemia C. Dermatitis D. Hepatomegaly E. Lymphadenopathy

C. Dermatitis D. Hepatomegaly E. Lymphadenopathy

RN is educating a client who is breast feeding her 2 wk old newborn regarding the nutritional requirements of newborns, according to the American Academy of Pediatrics. Which response by the mother would validate her understanding of the information received? A. I will feed him at least 30 cc of water daily. B. I need to give him iron supplements daily. C. I will give him Vitamin D supplements daily for the first 2 months of life. D. Since we live in a rural area, I must ensure he received adequate fluoride supplementation.

C. I will give him Vitamin D supplements daily for the first 2 months of life.

Which factor predisposes an infant to fluid imbalances? A. Decreased surface area B. Lower metabolic rate C. Immature kidney functioning D. Decreased daily exchange of extracellular fluid

C. Immature kidney functioning

RN is providing discharge instructions to a postpartum client following a c-section birth. The client reports leaking urine every time she sneezes or coughs. Which of the following interventions should the RN suggest? A. Sit ups B. Pelvic tilt exercises C. Kegel exercises D. Abdominal crunches

C. Kegel exercises

A 2 mo. old infant is admitted to a local health care facility with an axillary temp of 96.8 degrees F. Which observed manifestation would confirm the occurrence of cold stress in this client? A. Increased appetite B. Increase in body temp C. Lethargy and hypotonia D. Hyperglycemia

C. Lethargy and hypotonia

During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a RN finds the uterus to be firm, midline & at the level of the umbilicus. Which of the following findings should the RN interpret this data as being? A. Evidence of a possible vaginal hematoma B. Indication of a cervical or perineal laceration C. Normal postural discharge of lochia D. Abnormally excessive lochia rubra flow

C. Normal postural discharge of lochia

RN needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? A. After the newborn has received the initial feeding. B. 24 hours after admission to the nursery C. On admission to the nursery D. 4 hours after admission to the nursery.

C. On admission to the nursery

RN is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temp? A. Tape electronic thermometer probe to the abdominal skin. B. Obtain the temp orally C. Place electronic temp probe in the midaxillary area. D. Obtain the temp rectally.

C. Place electronic temp probe in the midaxillary area.

RN is assessing the temp of a newborn using a skin temp probe. Which point should the nurse keep in mind while taking the newborn's temp? A. Ensure that the newborn is laying on its abdomen B. Tape the temp probe on the forehead C. Place the temp probe over its liver D. Use the skin temp probe only in open bassinets.

C. Place the temp probe over its liver

RN cares for a newborn with a congenital cardiac anomaly. What component of nursing care is the priority for the newborn? A. Maintain oxygen saturation at 95% or above. B. Accompany the newborns to all radiologic exams C. Prevent pain as much as possible. D. Teach the parents to take pulse and blood pressure measurements.

C. Prevent pain as much as possible.

The care of a newborn with a cleft lip and palate before surgical repair includes a. little to no sucking. b gastrostomy feedings. c providing nonnutritive and nutritive sucking. d positioning infant in near-horizontal for feeding.

C. Providing nonnutritive and nutritive sucking

RN is providing discharge instructions for a client. At 4 wks postpartum, the client should contact her provider for which of the following client findings? A. Scant, nonodorous white vaginal discharge B. Uterine cramping during breastfeeding C. Sore nipple with cracks & fissures D. Decreased response with sexual activity

C. Sore nipple with cracks & fissures

RN is caring for a 2 y.o. child who has had 3 infections in the past 5 months. Which of the following long term complications is the child at risk for developing? A. Balance difficulties B. Prolonged hearing loss C. Speech delays D. Mastoiditis

C. Speech delays

RN determines that a newborn has a 1 min Apgar score of 5 points. What conclusion would the nurse make from this finding? A. The infant required immediate and aggressive interventions for survival. B. The infant is adjusting well to extrauterine life. C. The infant is experiencing moderate difficulty in adjusting to extrauterine life. D. The infant probably has either a congenital heart defect or an immature respiratory system.

C. The infant is experiencing moderate difficulty in adjusting to extrauterine life.

RN is caring for a client who's in active labor & becomes nauseous & vomits. Client is very irritable & feels the urge to have a BM. She states, "I've had enough. I can't do this anymore. I want to go home right now". Which of the following stages of labor is the client experiencing? A. Second stage B. Fourth stage C. Transition phase D. Latent phase

C. Transition phase

A nurse is caring for a child who is taking mannitol for cerebral edema. Which of the following adverse effects should the nurse monitor the child for and report to the provider? a. bradycardia b. weight loss c. confusion d. constipation

C. confusion

A nurse is caring for a school age client who possibly has Reye syndrome. Which of the following is a risk factor for developing this syndrome? a. recent history of infectious cystitis caused by Candida b. Recent history of bacterial otitis media c. Recent episode of gastroenteritis d. Recent episode of Haemophilus influenza meningitis

C. recent episode of gastroenteritis

A young child is diagnosed with vesicoureteral reflux. The nurse should know that this is usually associated with a. incontinence. b. urinary obstruction. C. recurrent kidney infections. d. infarction of renal vessels.

C. recurrent kidney infections.

RN is caring for a client who's in the 1st stage of labor & encouraging the client to void q2h. Which of the following statements should the RN make? A. "A full bladder increases the risk for fetal trauma" B. "A full bladder increases the risk for bladder infections" C. "A distended bladder will be traumatized by frequent pelvic exams" D. "A distended bladder reduces pelvic space needed for birth"

D. "A distended bladder reduces pelvic space needed for birth"

RN is caring for a toddler who has acute otitis media. Which of the following is the priority action for the nurse to take? A. Provide emotional support to the family. B. Educate the family on care of the child. C. Prevent clinical complications D. Administer analgesics.

D. Administer analgesics.

RN, while examining a newborn, observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? A. Bruising from the birth process. B. An immature autoregulation of blood flow. C. An allergic reaction to the soap used for the first bath. D. Concentration of immature blood vessels.

D. Concentration of immature blood vessels.

RN in L&D is planning care for a newly admitted client who reports she's in labor & having vaginal bleeding x 2 wks. Which of the following should the RN include in the plan of care? A. Inspect the introitus for prolapsed cord B. Perform a test to identify the ferning pattern C. Monitor station of the presenting part D. Defer vaginal examination

D. Defer vaginal examination

RN is assessing a child who has chronic renal failure. Which of the following findings should the RN expect? A. Flushed face B. Hyperactivity C. Weight gain D. Delayed growth

D. Delayed growth

RN is planning care of a child who has a UTI. Which of the following should the RN include? A. Administer an antidiuretic B. Restrict fluids C. Evaluate the child's self-esteem D. Encourage frequent voiding

D. Encourage frequent voiding

A 12 hour old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client? A. Tachycardia B. Hypotension C. Decreased LOC D. Fluid overload

D. Fluid overload

A nurse is caring for a child who has a terminal illness and reviews palliative care with an assistive personnel. Which of the following statements by the AP indicates understanding of this review? a. I'm sure the family is hopeful that the new medication will stop the illness b. I'll miss working with this client now that only nurses will be caring for him c. I will et all the client's personal objects out of his room d. I will listen and respond as the family talks about their child's life

D. I will listen and respond as the family talks about their child's life

RN is teaching a group of parents about communicable diseases. The RN should include that which of the following is the best method to prevent a communicable disease? A. Hand washing B. Avoiding persons who have active disease. C. Covering your cough D. Obtaining immunizations

D. Obtaining immunizations

RN is caring for a client who's using patterned breathing during labor. Client reports numbness & tingling in fingers. Which of the following actions should the RN take? A. Admin O2 via nasal cannula at 2L/min B. Apply a warm blanket C. Assist client to side-lying position D. Place O2 mask over client's nose & mouth

D. Place O2 mask over client's nose & mouth

RN is caring for a 5 hour old newborn. The physician has asked the nurse to maintain the newborn's temp between 97.7 and 99.5 degrees F. Which nursing intervention would be the best approach to maintaining the temp within the recommended range? A. Delay weighing the infant, as the scales may be cold. B. Use the stethoscope over the newborn's garment C. Place the newborn's crib close to the outer wall in the room. D. Place the newborn skin to skin with the mother.

D. Place the newborn skin to skin with the mother.

RN in the delivery room is planning to promote maternal-infant bonding for a client who just delivered. Which of the following is the priority action by the RN? A. Encourage the parents to touch & explore the neonates features B. Limit noise & interruption in the delivery room C. Place the neonate at the client's breast D. Position the neonate skin-to-skin on the client's chest

D. Position the neonate skin-to-skin on the client's chest

RN concludes that the father of an infant is not showing positive signs of parent-infant bonding. He appears very anxious & nervous when the infant's mother asks him to bring her the infant. Which of the following actions should the RN to promote father-infant bonding? A. Hand the father the infant & suggest that he change the diaper B. Ask the father why he's so anxious & nervous C. Tell the father that he'll grow accustomed to the infant D. Provide education about infant care when the father is present

D. Provide education about infant care when the father is present

RN is preparing to administer immunizations to a 4 month old infant. Which of the following is an appropriate action for the nurse to take in providing atraumatic care? A. Administer 81 mg of aspirin B. Use the Z track method when injecting C. Ask the parents to leave the room during the injection D. Provide sucrose solution on the pacifier.

D. Provide sucrose solution on the pacifier.

RN is reviewing the electronic monitor tracing of a client who's in active labor. RN should know that a fetus receives more O2 when which of the following appears on the tracing? A. Peak of uterine contraction B. Moderate variability C. FHR acceleration D. Relaxation between uterine contractions

D. Relaxation between uterine contractions

RN is caring for a child who has AIDS. Which of the following isolation precautions should the nurse implement? A. Contact B. Airborne C. Droplet D. Standard

D. Standard

The nurse is discussing home care with the mother of a 6-year-old child with hepatitis A. Part of the discharge teaching plan should include? a. Bed rest is important until 1 week after the icteric phase. b. The child should not return to school until 3 weeks after the icteric phase. c. Reassure the mother that hepatitis A cannot be transmitted to other family members. D. Teach infection control measures to family members

D. Teach infection control measures to family members

RN in labor & delivery unit receives a phone call from a client who reports that her contractions started about 2 hours ago, didn't go away when she had 2 glasses of water & rested, & became stronger since she started walking. Her contractions occur every 10 minutes lasting about 30 seconds. She hasn't had any vaginal fluid leaking. However, she saw some blood when she wiped after voiding. Based on this report, which of the following clinical findings should the RN recognize that the client was experiencing? A. Braxton Hicks contractions B. Rupture of membranes C. Fetal descent D. True contractions

D. True contractions

Dietary management of a child with inflammatory bowel disease (IBD) should include a. low protein. b. low calorie. c. high fiber. d. vitamin supplements.

D. Vitamin Supplements

RN is providing teaching to a new mother who is breast feeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breast fed newborns? Select all that apply. A. Formed in consistency B. Completely odorless C. Firm in shape D. Yellowish gold color E. Stringy to pasty consistency

D. Yellowish gold color E. Stringy to pasty consistency

A nurse is providing teaching to the parent of a child who has a new prescription for liquid oral iron supplements. Which of the following statements by the parent indicates an understanding of the teaching? a. I should take my child to the emergency department if his stools become dark b. My child should avoid eating citrus fruits while taking the supplements c. I should give the iron with milk to help prevent an upset stomach d. My child should take the supplement through a straw

D. my child should take the supplement through a straw

A child has a nasogastric (NG) tube after surgery for acute appendicitis. What is the purpose of the NG tube? a.Maintain electrolyte balance b.Maintain an accurate record of output c.Prevent the spread of infection d. Prevent abdominal distention

D. prevent abdominal distention

In a non-potty-trained child with nephrotic syndrome, what is the best way to detect fluid retention? a.Weigh the child daily. b. Test the urine for hematuria. c. Measure the abdominal girth weekly. d. Count the number of wet diapers.

Weigh the child daily.

The nurse is caring for a child with a Wilms' tumor. What is the most important nursing intervention preoperatively? a. Avoid abdominal palpation. b. Closely monitor the arterial blood gases. c. Prepare the child and family for long-term dialysis. d. Prepare the child and family for renal transplantation.

a. Avoid abdominal palpation.

In teaching a group of nursing students about factors that could lead to the development of urinary tract infections, which critical aspect should the nursing instructor focus on? a. Concept of urinary stasis b. Over distention of the bladder c. Urinary frequency d. Maintaining proper hydration

a. Concept of urinary stasis

In performing a work up for a school aged child who reports frequent abdominal pain symptoms, what information would be critical to collect in order to make an accurate clinical diagnosis? a. Find out the duration, onset and quality characteristics of the symptoms. b. Ask the child's parents for detailed information. c. Find out if the child has any food allergies or food intolerances. d. Take and document vital signs to establish a clinical baseline

a. Find out the duration, onset and quality characteristics of the symptoms.

In addition to presenting symptoms, what laboratory finding indicates nephrosis? a. Hypoalbuminemia b. Low specific gravity c. Decreased hematocrit d. Decreased hemoglobin

a. Hypoalbuminemia

What should the nurse consider when providing support to a family whose infant has just been diagnosed with biliary atresia? a. Liver transplantation may be needed eventually. b. Death usually occurs by 6 months of age. c. The prognosis for full recovery is excellent. d. Children with surgical correction live normal lives.

a. Liver transplantation may be needed eventually.

The nurse is caring for a child with probable intussusception. The child had diarrhea before admission, but while waiting for administration of air pressure to reduce the intussusception, the child passed a normal brown stool. What is the most appropriate nursing action? a. Notify the physician. b. Measure the abdominal girth. c. Auscultate for bowel sounds. d. Take vital signs, including blood pressure.

a. Notify the physician

When considering Crohn's and Ulcerative Colitis (UC) as disease states, which clinical symptoms may appear to be common presentations in both? a. Rashes and joint pain b. Rectal bleeding c. Growth restriction d. Fistulas and strictures

a. Rashes and joint pain

A nurse is caring for an infant with a suspected urinary tract infection (UTI). Based on the nurse's knowledge of UTIs, which clinical manifestation would be observed? (Select all that apply.) a. Vomiting b. Jaundice c. Swelling of the face d. Persistent diaper rash e. Failure to gain weight

a. Vomiting d. Persistent diaper rash e. Failure to gain weight

The nurse is concerned with the prevention of communicable disease. Primary prevention results from a. immunizations. b. early diagnosis. c. strict isolation. d. treatment of disease.

a. immunizations.

Which urine test would be considered abnormal? a. pH: 4 b. Specific gravity: 1.020 c. Protein level: absent d. Glucose level: absent

a. pH: 4

Parents of a newborn bring their male son to the emergency room. The infant appears fretful and the parents state that he has not voided in several hours. Inspection of the penis reveals edema and the nurse is unable to retract the foreskin. Based on this assessment, what would the nurse anticipate as the priority action? a. Perform an ultrasound to determine if there is urinary retention. b. Inform the ER physician of the patient's condition. c. Ask the parents specifically how long the infant has not voided. d. Continue to monitor the patient in the ER setting

b. Inform the ER physician of the patient's condition.

An infant with neurologic impairment and delay is receiving several medications. A proton pump inhibitor is one of the medications the infant is receiving. Which medication(s) is/are proton pump inhibitor(s)? (Select all that apply.) a. Ranitidine (Zantac) b. Omeprazole (Prilosec) c. Pantoprazole (Protonix) d. Glycopyrrolate (Robinul) e. Bethanechol (Urecholine)

b. Omeprazole (Prilosec) c. Pantoprazole (Protonix)

What is described as the time interval between early manifestations of a disease and the overt clinical syndrome? a. Incubation period b. Prodromal period c. Desquamation period d. Period of communicability

b. Prodromal period

Which parameters would confirm clinical diagnosis of urinary infections (UTI) in young children? (Select all that apply.) a. Fever b. Pyuria c. Clean catch specimen reported as being cloudy in appearance. d. 50,000 or greater colonies per mL indicating uropathic organism.

b. Pyuria c. Clean catch specimen reported as being cloudy in appearance.

A child has been diagnosed with hepatitis A and received treatment. Based on this information the nurse determines that a. the illness was transmitted via blood route. b. immunity has been acquired for this type. c. crossover immunity is present for all types of hepatitis. d. the patient will now be a carrier for this type

b. immunity has been acquired for this type

Management of the child with a peptic ulcer often includes a. milk at frequent intervals. b. proton pump inhibitors. c. antacids 1 and 3 hours before meals and at bedtime. d. coping with stress and adjusting to chronic illness

b. proton pump inhibitors.

A 6-year-old child with acute renal failure (ARF) is being transferred out of the intensive care unit. Which children, considering their diagnoses, would be the most appropriate roommate for this child? a. 6-year-old child with pneumonia b. 4-year-old child with gastroenteritis c. 5-year-old child who has a fractured femur d. 7-year-old child who had surgery for a ruptured appendix

c. 5-year-old child who has a fractured femur

Which diet is most appropriate for the child with celiac disease? a. Salt-free diet b. Phenylalanine-free diet c. Low-gluten diet d. High-calorie, low-protein, low-fat diet

c. Low-gluten diet

The parent of a child hospitalized with acute glomerulonephritis (AGN) asks the nurse why blood pressure readings are being taken so often. Based on the nurse's knowledge of AGN, the most appropriate response by the nurse is a.blood pressure fluctuations are a common side effect of antibiotic therapy. b. blood pressure fluctuations are a sign that the condition has become chronic. c. acute hypertension must be anticipated and identified. d. hypotension leading to sudden shock can develop at any time.

c. acute hypertension must be anticipated and identified.

Urine specimen results for a pediatric patient note greater than 100,000 colony forming units (CFUs) but the patient denies any complaints with urination. Based on this information the nurse would suspect that the patient has a. subacute pyelonephritis. b. pyuria. c. asymptomatic bacteriuria. d. febrile UTI.

c. asymptomatic bacteriuria.

A 3-year-old child is scheduled for surgery to remove a Wilms' tumor from one kidney. The parents ask the nurse about what treatments, if any, will be necessary after recovery from surgery. The nurse's explanation should be based on knowledge that a. no additional treatments are usually necessary. b. chemotherapy is usually not necessary. c. chemotherapy with or without radiotherapy is indicated. d. kidney transplant will be indicated within the yea

c. chemotherapy with or without radiotherapy is indicated.

A nurse is caring for a child who is dying. Which of the following are findings of impending death? (select all that apply) a. heightened sense of hearing b. tachycardia c. difficulty swallowing d. sensation of being cold e. cheyne-stokes breathing

c. difficulty swallowing e. cheyne-stokes breathing

A 5-year-old child has been sent to the school nurse for urinary incontinence three times in the past 2 days. The nurse should recommend to the child's parent that the first action is to have the child evaluated for a. school phobia. b. emotional causes. c. possible urinary tract infection. d. possible structural defects of urinary tract.

c. possible urinary tract infection.

The school nurse is concerned about an outbreak of chickenpox because two children at the school have cancer and are immunodeficient from chemotherapy. The most appropriate recommendation by the school nurse is that a. no precautions necessary. b. acyclovir (Zovirax) should be taken to minimize the symptoms of chickenpox. c. varicella-zoster immune globulin (VZIG) to prevent chickenpox. d. temporarily stopping chemotherapy will allow the immune system to recover.

c. varicella-zoster immune globulin (VZIG) to prevent chickenpox.

The school nurse is discussing prevention of acquired immunodeficiency syndrome (AIDS) with some adolescents. Which statement is appropriate to include? a. The virus is easily transmitted. b. The virus is transmitted only through blood. c.Intravenous drug users should not share needles. d. Condoms should be used if a person is sexually active and homosexual.

c.Intravenous drug users should not share needles.

What is an appropriate nursing intervention while the child with nephrotic syndrome is confined to bed? a. Restrain the child as necessary. b. Discourage the parents from holding the child. c. Do passive range-of-motion exercises once a day. d. Adjust activities to the child's tolerance level

d. Adjust activities to the child's tolerance level

What is an important nursing consideration when caring for a child with end-stage renal disease (ESRD)? a. Children with ESRD usually adapt well to the minor inconveniences of treatment. b. Children with ESRD require extensive support until they outgrow the condition. c. Multiple stresses are placed on children with ESRD and their families until the illness is cured. d. Multiple stresses are placed on children with ESRD and their families because their lives are maintained by drugs and artificial means

d. Multiple stresses are placed on children with ESRD and their families because their lives are maintained by drugs and artificial means

A child is exhibiting signs of clinical dehydration. Which laboratory value would support a diagnosis of hypertonic dehydration? a. Serum sodium level of 135 mEq/dL b. Plasma osmolality of 275 mOsm/L c. calculation of loss of body fluid weight at 25 mL/kg d. Serum sodium level of 150 mEq/dL

d. Serum sodium level of 150 mEq/dL

A toddler is hospitalized with acute renal failure (ARF) secondary to severe dehydration. The nurse should assess the child for what possible complications? a. Hypotension b. Hypokalemia c. Hypernatremia d. Water intoxication

d. Water intoxication

An appropriate nursing intervention for a child with nephrotic syndrome on bed rest is to a. restrain the child as necessary. b. discourage the parents from holding the child. c. do passive range-of-motion exercises once a day. d. adjust activities to the child's tolerance level.

d. adjust activities to the child's tolerance level.

External defects of the genitourinary tract, such as hypospadias, are usually repaired as early as possible to ensure a. prevention of urinary tract complications. b. prevention of separation anxiety. c. acceptance of hospitalization. d. development of normal body image.

d. development of normal body image.

The nurse assesses a neonate immediately after birth. Clinical sign-symptom of tracheoesophageal fistula is a. jaundice. b. bile-stained vomitus. c. absence of sucking. d. excessive amount of frothy saliva in the mouth

d. excessive amount of frothy saliva in the mouth

A nurse is caring for a 4 month old infant who has meningitis. Which of the following findings is associated with this diagnosis? a. depressed anterior fontanel b. constipation c. presence of the rooting reflex d. high pitched cry

d. high pitched cry

When evaluating the extent of an infant's dehydration, the nurse should recognize that the symptoms of severe dehydration (15%) are a. tachycardia, decreased tears, 5% weight loss. b. normal pulse and blood pressure, intense thirst. c. irritability, moderate thirst, normal eyes and fontanels. d. tachycardia, parched mucous membranes, sunken eyes and fontanels

d. tachycardia, parched mucous membranes, sunken eyes and fontanels

The assessment of a pregnant client, who is toward the end of her third trimester, reveals that she has increased prostaglandin levels. For which factors should the nurse assess the client? Select all that apply. A. Reduction in cervical resistance B. Myometrial contractions. C. Boggy appearance of the uterus. D. Softening and thinning of the cervix. E. Hypotonic character of the bladder.

A. Reduction in cervical resistance B. Myometrial contractions. D. Softening and thinning of the cervix.

A pregnant client requires administration of a epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block? Select all that apply. A. Spinal abnormality B. Hypovolemia C. Varicose veins D. Coagulation defects E. Skin rashes or bruises

A. Spinal abnormality B. Hypovolemia D. Coagulation defects

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing? A. Inhale and exhale through the mouth at a rate of 4 breaths every 5 seconds B. Inhale slowly through the nose and exhale through pursed lips C. Punctuated breathing by forceful exhalation through pursed lips every few breaths. D. Hold breath for 5 seconds after every 3 breaths.

B. Inhale slowly through the nose and exhale through pursed lips

Which nursing intervention should the nurse perform when assessing for fetal well-being through abdominal ultrasonography in a client? A. Inform the client that she may feel hot initially B. Instruct the client to refrain from emptying her bladder. C. Instruct the client to report the occurrence of fever. D. Obtain and record vital signs of the client.

B. Instruct the client to refrain from emptying her bladder.

A client who is in her 6th week is being seen for a routine prenatal care visit. The client asks the nurse about changes in her eating habits that she should make during her pregnancy The client informs the nurse that she is a vegetarian. The nurse knows that she has to monitor the client for which risks arising from her vegetarian diet? Select all that apply A. Epistaxis B. Iron-defiency anemia C. Decreased mineral absorption D. Constipation E. Low gestational weight gain

B. Iron-defiency anemia C. Decreased mineral absorption E. Low gestational weight gain

Client who's 8 weeks gestation tells the RN that she isn't sure she's happy about being pregnant. Which of the following responses should the RN make? A. I'll inform the provider you're having these feelings B. It's normal to have these feelings during the first few months of pregnancy C. You should be happy that you're going to bring new life into the world D. I'm going to make you an appointment with the counselor for you to discuss these thoughts

B. It's normal to have these feelings during the first few months of pregnancy

RN is caring for a client who's in preterm labor and is scheduled to undergo an amniocentesis. The RN should evaluate which of the following tests to assess fetal lung maturity? A. Alpha-fetoprotein (AFP) B. Lecithin/ sphingomyelin (L/S) ratio C. Kleihauer-Betke test D. Indirect Coombs' test

B. Lecithin/ sphingomyelin (L/S) ratio

A client in her 2nd trimester reports discomfort during sexual activity. Which instruction should a nurse provide? A. Perform frequent douching, and use lubricants. B. Modify sexual positions to increase comfort. C. Restrict contact to alternative, noncoital mode of sexual expression. D. Perform stress relieving and relaxing exercises.

B. Modify sexual positions to increase comfort.

A client is administered combined spinal-epidural analgesia is showing signs of hypotension and associated FHR changes. What intervention should the nurse perform to manage the changes? A. Assist the client to a supine position B. Provide supplemental oxygen C. Discontinue IV fluid D. Turn the client to her right side

B. Provide supplemental oxygen

A nurse is caring for a client in her second trimester of pregnancy. During a regular follow-up visit, the client reports varicosities of the legs. Which instruction should the nurse provide to help the client alleviate varicosities of the legs? A. Avoid sitting in one position for long B. Refrain from crossing legs when sitting for long periods. C. Apply heating pads on extremities D. Refrain from wearing any kind of stockings.

B. Refrain from crossing legs when sitting for long periods.

A 29 week gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next? A. Prepare the client for birth. B. Assess the clients cervical status C. Notify the health care provider D. Perform Leopold's maneuvers

C. Notify the health care provider

RN is teaching a group of women who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the RN include in the teaching? Select all that apply. A. Avoid any lifting B. Perform Kegel exercises BID C. Perform pelvic rock exercises daily D. Use proper body mechanics E. Avoid constrictive clothing

C. Perform pelvic rock exercises daily D. Use proper body mechanics

A client in her 3rd trimester wishes to use the method of feeding formula to her baby. What instruction should the nurse provide? A. Mix one scoop of powder with an oz of water. B. Feed the infant every 8 hrs C. Serve the formula and room temperature D. Refrigerate any leftover formula.

C. Serve the formula and room temperature

A pregnant client wants to know why the labor of a first time pregnant women usually lasts longer than that of a woman who has already delivered once and is pregnant a second time.What explanation should the nurse offer the client? A. Braxton Hicks contractions are not strong enough during first pregnancy. B. Contractions are stronger during the first pregnancy. C. The cervix takes around 12-16 hours to dilate during first pregnancy D. Spontaneous rupture of membranes occurs during first pregnancy.

C. The cervix takes around 12-16 hours to dilate during first pregnancy

A pregnant client reports an increase in a thick, whitish vaginal discharge. Which response made by the nurse, would be most appropriate? A. You should refrain from any sexual activity. B. You need to be assessed for a fungal infection. C. This discharge is normal during pregnancy. D. Use local antifungal agents regularly.

C. This discharge is normal during pregnancy.

A client in her 2nd trimester of pregnancy is anxious about the blotchy, brown pigmentation on her forehead and cheeks. She also reports increased pigmentation on her breasts and genitalia. Which statement, by the nurse, is most appropriate? A. I will let the HCP know about the pigmentation. B. I understand your concern; I would be concerned too. C. This is called facial melanoma and should fade after your delivery. D. I can tell you are anxious. Are there any other things worrying you?

C. This is called facial melanoma and should fade after your delivery.

RN in a prenatal clinic is caring for a client who's pregnant and experiencing episodes of maternal hypotension. The client asks the RN what causes these episodes. Which of the following responses should the RN make? A. This is due to an increase in blood volume B. This is due to pressure from the uterus on the diaphragm C. This is due to the weight of the uterus on the vena cava D. This is due to increased cardiac output

C. This is due to the weight of the uterus on the vena cava

A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm? A. To reduce boggy nature of the uterus B. To remove pieces left attached to uterine wall C. To constrict the uterine blood vessels D. To lessen the chances of conducting an episiotomy.

C. To constrict the uterine blood vessels

A client in her 39th week of gestation reports swelling in the legs after standing for long periods of time. The nurse recognizes that this factor increases the client's risk for which condition? A. Hemorrhoids B. Embolism C. Venous thrombosis D. Supine hypotension syndrome

C. Venous thrombosis

A client in her 29th week of gestation reports dizziness and clamminess when assuming a supine position. During the assessment, the nurse observes there is a marked decrease in the client's BP. Which intervention should the nurse implement to help alleviate this client's condition? A. Keep the client's legs slightly elevated. B. Place the client in the orthopneic position C. Keep the head of the bed slightly elevated D. Place the client in the left lateral position

D. Place the client in the left lateral position

A nurse caring for a client in labor has asked her to perform Lamaze breathing techniques to avoid pain. Which should the nurse keep in mind to promote effective Lamaze-method breathing? A. Ensure deep abdominopelvic breathing. B. Ensure abdominal breathing during contractions C. Ensure client's concentration on pleasurable sensations. D. Remain quiet during client's period of imagery.

D. Remain quiet during client's period of imagery.

RN is caring for a client who's diagnosis of ruptured ectopic pregnancy. Which of the following findings is seen with this condition? A. No alteration in menses B. Transvaginal ultrasound indicating a fetus in the uterus C. Serum progesterone greater than the expected reference range D. Report of severe shoulder pain

D. Report of severe shoulder pain

Pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned RN observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions? A. Effacement and dilation of cervix B. Shortening of upper uterine segment C. Reduction in length of cervical canal D. Restoration of blood flow to uterus and placenta

D. Restoration of blood flow to uterus and placenta

RN in a clinic receives a phone call from a client who believes she's pregnant and would like to be tested in the clinic to confirm her pregnancy. Which of the following info should the RN provide the client? A. You should wait until 4 weeks after conception to be tested B. You should be off any medications for 24 hours prior to the test. C. You should be NPO for at least 8 hours prior to the test D. You should collect urine from the first AM void

D. You should collect urine from the first AM void

RN is reviewing the health record of a client who's pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the RN expect? Select all that apply. A. Montgomery's glands B. Goodell's sign C. Ballottement D. Chadwick's sign E. Quickening

B. Goodell's sign C. Ballottement D. Chadwick's sign

A pregnant client wishes to know if sexual intercourse would be safe during her pregnancy. Which should the nurse confirm before educating the client regarding sexual behavior during pregnancy? A. Client does not have an incompetent cervix. B. Client does not have anxieties and worries C. Client does not have anemia D. Client does not experience facial and hand edema.

A. Client does not have an incompetent cervix.

A pregnant client arrives at the maternity clinic reporting constipation. Which factors could be the cause of constipation during pregnancy? Select all that apply. A. Decreased activity level. B. Increase in estrogen levels C. Use of iron supplements. D. Reduced stomach acidity E. Intestinal displacement.

A. Decreased activity level. C. Use of iron supplements. E. Intestinal displacement.

RN is caring for a client who's pregnant and to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? Select all that apply. A. Decreased fetal movements B. Intrauterine growth restriction (IUGR) C. Postmaturity D. Placenta previa E. Amniotic fluid emboli

A. Decreased fetal movements B. Intrauterine growth restriction (IUGR) C. Postmaturity

A 39 week gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? A. Determine if the client is in true or false labor B. Ask if this is the client's first pregnancy C. Notify the health care provider D. Assess to see if the client has any drug allergies.

A. Determine if the client is in true or false labor

A client in her 2nd trimester arrives at a health care facility for a follow up visit. During the exam, the client reports constipation. Which instruction should the nurse offer to help alleviate constipation? A. Ensure adequate hydration and bulk in the diet B. Avoid spicy or greasy food in meals C. Practice kegel exercises D. Avoid lying down for 2 hours after meals.

A. Ensure adequate hydration and bulk in the diet

A 28 y/o client states that she did not have her menses for the past 3 months and suspects she is pregnant. Which should the nurse do next? A. Determine at what age the client began menses. B. Have the client take a pregnancy test. C. Assess the client for a fetal heart tone. D. Ask the client the date her last menses ended.

B. Have the client take a pregnancy test.

A nurse is assigned to conduct an admission assessment on the phone for a pregnant client. Which information should the nurse obtain from the client? Select all that apply. A. Estimated due date B. History of drug use C. Characteristics of contractions D. Appearance of vaginal blood E. History of drug allergy

A. Estimated due date C. Characteristics of contractions D. Appearance of vaginal blood

The nurse explains Leopold's maneuvers to a pregnant client. For which purpose are these performed? Select all that apply. A. Determining the presentation of the fetus B. Determining the position of the fetus C. Determining the lie of the fetus D. Determining the weight of the fetus E. Determining the size of the fetus

A. Determining the presentation of the fetus B. Determining the position of the fetus C. Determining the lie of the fetus

Client who's 7 weeks gestation is experiencing N/V in the AM. Which of the following information should the RN include in the teaching? A. Eat crackers or plain toast before getting out of bed B. Awaken during the night to eat a snack C. Skip breakfast and eat lunch after nausea has subsided D. Eat a large evening meal

A. Eat crackers or plain toast before getting out of bed

A pregnant client states that she was unable to breastfeed her last child because her breasts did not produce milk. She desires to breastfeed this child. Which hormones would the nurse monitor during this pregnancy? A. Estrogen and human placental lactogen B. Relaxin and human chorionic gonadotropin. C. Progesterone and relaxin D. Oxytocin and progesterone

A. Estrogen and human placental lactogen

RN is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? A. External electronic fetal monitoring B. Fetal blood pH C. Fetal oxygen saturation D. Fetal position

A. External electronic fetal monitoring

RN in ED is caring for a client who reports abrupt, shart, right sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states she missed one menstrual cycle and cannot be pregnant because she has an intrauterine device. The nurse should expect which of the following? A. Missed abortion B. Ectopic pregnancy C. Severe preeclampsia D. Hydatidiform mole

B. Ectopic pregnancy

A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's vital signs? A. Every 15 mins B. Every 30 mins C. Every 45 mins D. Every 1 hr

B. Every 30 mins

Pregnant client is in labor has to undergo a sonogram to confirm fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess? A. Uterine abnormalities B. Fetal anomalies C. Congential anomalies D. Prematurity

B. Fetal anomalies

RN in a prenatal clinic is caring for a client who's in the 1st trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the RN interpret this information? Select all that apply. A. Client has delivered 1 newborn at term B. Client has experienced no preterm labor C. Client has been through active labor D. Client has had 2 prior pregnancies E. Client has 1 living child

A. Client has delivered 1 newborn at term D. Client has had 2 prior pregnancies E. Client has 1 living child

RN in a prenatal clinic is providing education to a client who's in the 8th week of gestation. The client states that she doesn't like milk. Which of the following foods should the RN recommend as a good source of calcium? A. Dark green leafy vegetables B. Deep red or orange vegetables C. White bread & rice D. Meat, poultry & fish

A. Dark green leafy vegetables

RN is teaching a client who is at 6 weeks gestation about common discomforts of pregnancy. Which of the following findings should the RN include in the teaching? Select all that apply A. Breast tenderness B. Urinary frequency C. Epistaxis D. Dysuria E. Epigastric pain

A. Breast tenderness B. Urinary frequency C. Epistaxis

A client in her 3rd month arrives at the health care facility for a regular follow-up visit. The client reports discomfort due to increased urinary frequency. Which instruction should the nurse offer the client to reduce the client's discomfort? A. Avoid consumption of caffeinated drinks. B. Drink fluids with meals rather than between meals C. Avoid an empty stomach at all times D. Much on dry crackers and toast in the early morning.

A. Avoid consumption of caffeinated drinks.

RN is providing care for a client who's 32 wks gestation and has a placenta previa. The RN notes that the client is actively bleeding. Which of the following types of medications should the RN anticipate the provider will prescribe? A. Betamethasone B. Indomethacin C. Nifedipine D. Methylergonovine

A. Betamethasone

A client in her 39th week of gestation arrives at the maternity clinic stating that earlier in her pregnancy, she experienced shortness of breath. However, for the past few days, she's been able to breathe easily, but she also has begun to experience increased urinary frequency. A nurse is assigned to perform the physical examination of the client. Which observation is most likely? A. Fundal height has dropped since the last recording B. Fundal height is at its highest level at the xiphoid process. C. The fundus is at the level of the umbilicus and measures 20 cm D. The lower uterine segment and cervix have softened.

A. Fundal height has dropped since the last recording

RN is caring for a pregnant client during labor. Which methods should the nurse use to provide comfort to the pregnant client. Select all that apply. A. Hand holding B. Chewing gum C. Massaging D. Acupressure E. Prescribed pain killers

A. Hand holding C. Massaging D. Acupressure

RN is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client, as the client progresses through birth? Select all that apply. A. Increase in HR B. Increase in BP C. Increase in RR D. Slight decrease in in body temp E. Increase in gastric emptying and pH.

A. Increase in HR B. Increase in BP C. Increase in RR

A client in labor is administered lorazepam to help her relax enough so that she can participate effectively during her labor process rather than fighting against it. For which adverse effect of the drug should the nurse monitor? A. Increased sedation B. Newborn respiratory depression C. Nervous system depression D. Decreased alertness

A. Increased sedation

A pregnant client has opted for hydrotherapy for pain management during labor. Which should the nurse consider when assisting the client during the birthing process? A. Initiate the technique only when the client is in active labor B. Do not allow the client to stay in the bath for long C. Ensure that the water temp exceeds body temp D. Allow the client into the water only if her membranes have ruptured

A. Initiate the technique only when the client is in active labor

RN is caring for a client who is pregnant and states that her LMP was April 1st. Which of the following is the client's estimated date of delivery? A. Jan. 8 B. Jan. 15 C. Feb. 8 D. Feb. 15

A. Jan. 8

A nurse is required to obtain the fetal heart rate for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly? A. Lower quadrant of the maternal abdomen B. At the level of the maternal umbilicus C. Above the level of the maternal umbilicus D. Just below the maternal umbilicus

A. Lower quadrant of the maternal abdomen

RN is caring for a client who is in the first stage of labor. The client is experiencing extreme pain due to the labor. The nurse understands which to be causes of the extreme pain in the client? Select all that apply. A. Lower uterine segment distention B. Fetus moving along the birth canal C. Stretching and tearing of structures D. Spontaneous placental expulsion E. Dilation of cervix.

A. Lower uterine segment distention C. Stretching and tearing of structures E. Dilation of cervix.

A nurse is assigned to educate a pregnant client regarding the changes in the structures of the respiratory system taking place during pregnancy. Which conditions are associated with such changes? Select all that apply. A. Nasal and sinus stuffiness B. Persistent cough C. Nosebleed D. Kussmaul respirations E. Thoracic rather than abdominal breathing.

A. Nasal and sinus stuffiness C. Nosebleed E. Thoracic rather than abdominal breathing.

RN is caring for a client who is at 14 wks gestation and has hyperemesis gravidarum. The RN should identify that which of the following are risk factors for the client? Select all that apply. A. Obesity B. Multifetal pregnancy C. Maternal age >40 years D. Migraine headache E. Oligohydramnios

A. Obesity B. Multifetal pregnancy D. Migraine headache

A pregnant client has come to a health care facility for a physical exam. Which assessments should a nurse perform when doing a physical exam of the head and neck? Select all that apply. A. Previous injuries and sequelae B. Eye movements C. Levels of estrogen D. Limitations in ROM E. Thyroid gland enlargement

A. Previous injuries and sequelae D. Limitations in ROM E. Thyroid gland enlargement

A client in her 20th week of gestation expresses concern about her 5 y/o son, who is behaving strangely by not approaching her anymore. He does not seem to be taking the news of a new family member very well. Which of the following strategies can the discuss with the mother to deal with the situation? A. Provide constant reinforcement of love and care to the child. B. Avoid talking to the child about the new arrival. C. Pay less attention to the child to prepare him for the future D. Consult a child psychologist about the situation.

A. Provide constant reinforcement of love and care to the child.

RN is assigned the task of educating a pregnant client about birth. Which nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive birth experience? Select all that apply. A. Provide the client clear info on procedures involved B. Encourage the client to have a sense of mastery and self control C. Encourage the client to have a positive reaction to pregnancy D. Instruct the client to spend some time alone each day E. Instruct the client to begin changing the home environment.

A. Provide the client clear info on procedures involved B. Encourage the client to have a sense of mastery and self control C. Encourage the client to have a positive reaction to pregnancy

RN is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates MgSO4 toxicity? Select all that apply. A. RR <12 bpm B. Urinary output < 30mL/hr C. Hyperreflexic deep-tendon reflexes D. Decreased LOC E. Flushing & sweating

A. RR <12 bpm B. Urinary output < 30mL/hr D. Decreased LOC

A client in her 10th week of gestation arrives at the maternity clinic reporting morning sickness. The nurse needs to inform the client about the body system adaptations during pregnancy. Which factors correspond to the morning sickness period during pregnancy? Select all that apply. A. Reduced stomach acidity B. Elevated hCG C. Increased RBC production D. Increased estrogen level E. Elevated hPL

A. Reduced stomach acidity B. Elevated hCG D. Increased estrogen level

A client experiencing contractions presents at a clinic. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? A. These contractions help in softening and ripening the cervix. B. These contractions increase the release of prostaglandins. C. These contractions increase oxytocin sensitivity. D. These contractions make maternal breathing easier.

A. These contractions help in softening and ripening the cervix.

A pregnant client has come to a health care provider for her first prenatal visit. The nurse needs to document useful information about the past health history. What are goals of the nurse in the history taking process? Select all that apply. A. To prepare a plan of care that suits the client's lifestyle B. To develop a trusting relationship with the client C. To prepare a plan of care for the pregnancy D. To assess the client's sexual health E. To urge the client to achieve an optimal body weight.

A. To prepare a plan of care that suits the client's lifestyle B. To develop a trusting relationship with the client C. To prepare a plan of care for the pregnancy

RN is caring for a pregnant client in labor observes that the FHR is below 110 beats per min. Which interventions should the nurse perform? Select all that apply. A. Turn the client on her left side. B. Reduce IV fluid rate C. Administer oxygen by mask D. Assess client for underlying causes E. Ignore questions from the client.

A. Turn the client on her left side. C. Administer oxygen by mask D. Assess client for underlying causes

RN is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contractions? Select all that apply. A. Uterine resting tone B. Frequency of contractions C. Change in temperature D. Change in blood pressure E. Intensity of contractions

A. Uterine resting tone B. Frequency of contractions E. Intensity of contractions

A nurse is caring for a pregnant client in her 2nd trimester. The nurse educates the client to look for which danger sign of pregnancy needing immediate attention by the physician? A. Vaginal bleeding B. Painful urination C. Severe, persistent vomiting D. Lower abdominal and shoulder pain

A. Vaginal bleeding

RN is caring for a client who's pregnant and reviewing signs of complications the client should promptly report to the provider. Which of the following complications should the RN include in the teaching? A. Vaginal bleeding B. Swelling of the ankles C. Heartburn after eating D. Lightheadedness when lying back

A. Vaginal bleeding

The most important prevention method for the spread of any communicable disease is a. Hand washing. b. immunizations as secondary prevention. c. use of appropriate broad spectrum antibiotics. d. isolation from infectious agents.

A. hand washing

RN is reviewing findings of a client's biophysical profile (BPP). The RN should expect which of the following variables 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

B. Fetal breathing movement C. Fetal tone E. Amniotic fluid volume

RN in a prenatal clinic is caring for four clients. Which of the following client's weight gain should the RN report to the provider? A. 1.8 kg (4lb) weight gain & in her 1st trimester B. 3.6 kg (8lb) weight gain in her 1st trimester C. 6.8 kg (15lb) in her 2nd trimester D. 11.3 kg (25lb) in her 3rd trimester

B. 3.6 kg (8lb) weight gain in her 1st trimester

A nurse is educating a client about the various psychological feelings experienced by a woman and her partner during pregnancy. Which feeling is expressed by the expectant partner during the second trimester of pregnancy? A. Ambivalence along with extremes of emotions B. Confusion when dealing with the partner's mood swings C. Preparation for the new role as a parent and negotiating his or her role during labor D. Sympathetic response tot he partner's pregnancy.

B. Confusion when dealing with the partner's mood swings

RN is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next? A. Continue to monitor the client B. Continue to massage the client's fundus C. Administer oxygen to the client D. Assess the client's vaginal bleeding

B. Continue to massage the client's fundus

A client in her 3rd trimester of pregnancy arrives at a health care center with a report of cramping and low back pain; she also notes that she is urinating more frequently and that her breathing has become easier the past few days. Physical exam conducted by the nurse indicates that the edema of the lower extremities, along with an increase in vaginal discharge. What should the nurse do next? A. Notify the health care provider. B. Continue to monitor the client. C. Assess the client's BP D. Prepare the client for birth.

B. Continue to monitor the client.

A pregnant client's LMP was March 10. Using Naegele's rule, the nurse estimates the date of birth to be: A. January 7 B. December 17 C. February 21 D. January 30

B. December 17

RN is reviewing a new Rx for ferrous sulfate with a client who's at 12 wks gestation. Which of the following statements by the client indicates understanding of the teaching? A. "I'll take this pill with my breakfast" B. "I'll take this med with a glass of milk" C. "I plan to drink more OJ while taking this pill" D. "I plan to add more calcium-rich foods to my diet while taking this med

C. "I plan to drink more OJ while taking this pill"

RN is teaching a client who's pregnant about the amniocentesis procedure. Which of the following statements should the RN include in the teaching? A. "You'll lay on your right side during the procedure" B. "You should not eat anything for 24 hours prior to the procedure" C. "You should empty your bladder prior to the procedure" D. "The test is done to determine gestational age"

C. "You should empty your bladder prior to the procedure"

The nurse caring for a client in preterm labor observes abnormal FHR patterns. Which nursing intervention should the nurse perform next? A. Application of vibroacoustic stimulation B. Tactile stimulation C. Administration of oxygen by mask D. Fetal scalp stimulation

C. Administration of oxygen by mask

A pregnant client has come to a clinic for a pelvic exam. What assessments should a nurse perform when examining external genitalia? A. Cervix is smooth, long, thick and closed B. Bluish coloration of cervix and vaginal mucosa. C. Any infection due to hematomas, varicosities, and inflammation D. Hemorrhoids, massess, prolapse, and lesions

C. Any infection due to hematomas, varicosities, and inflammation

A pregnant client in her first trimester of pregnancy reports spontaneous, irregular, painless contractions. What does this indicate? A. Preterm labor B. Infection of the GI tract C. Braxton Hicks contractions D. Acid indigestion

C. Braxton Hicks contractions

RN is monitoring a pregnant client admitted to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the FHR with the doppler at least how often? A. Every 15-30 mins B. Every 30 mins C. Every hour D. Continously

C. Every hour

RN at an antepartum clinic is caring for a client who's at 4 months gestation. The client reports continued N/V and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the RN expect? A. Hyperemesis gravidarum B. Threatened abortion C. Hydatidiform mole D. Preterm labor

C. Hydatidiform mole

A 28 y/o client who has just conceived arrives at a health care facility for her first prenatal visit to undergo a physical exam. Which intervention should the nurse perform to prepare the client for the physical exam. A. ensure that the client is laying down B. Ensure that the client's family is present C. Instruct the client to empty her bladder D. Instruct the client to keep taking deep breaths.

C. Instruct the client to empty her bladder

Pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position? A. Long axis of fetus is at 60 degrees to that of the client B. Long axis of fetus is parallel to that of the client C. Long axis of fetus is perpendicular to that of client. D. Long axis of fetus is at 45 degrees to that of client.

C. Long axis of fetus is perpendicular to that of client.

RN is caring for a client who's pregnant and undergoing a nonstress test. The client asks why the RN is using an acoustic vibration device. Which of the following responses should the RN make? A. "It's used to stimulate uterine contractions" B. "It will decrease the incidence of uterine contractions" C. "It lulls the fetus to sleep" D. "It awakens a sleeping fetus"

D. "It awakens a sleeping fetus"

A client in the 3rd trimester has to travel a long distance by car. The client is so anxious about the effect that travel may have on her pregnancy. Which instruction should the nurse provide to promote easy and safe travel for the client? A. Activate the air bag in the car B. Use a lap belt that crosses over the uterus C. Apply a padded shoulder strap properly D. Always wear a 3 point seat belt.

D. Always wear a 3 point seat belt.

A pregnant client in her 12th week of gestation has come to a health care center for a physical exam of her abdomen. Where should the nurse palpate for the fundus in this client? A. At the umbilicus B. Below the ensiform cartilage C. Midway between the symphysis and umbilicus D. At the symphysis pubis

D. At the symphysis pubis

RN is caring for a client who's receiving IV magnesium sulfate. Which of the following meds should the RN anticipate administering if MgSO4 toxicity is suspected? A. Nifedipine B. Pyridoxine C. Ferrous sulfate D. Calcium gluconate

D. Calcium gluconate

A nurse is caring for a client in labor who is delivering. For which fetal response should the nurse monitor? A. Decrease in arterial carbon dioxide pressure. B. Increase in fetal breathing movements C. Increase in fetal oxygen pressure D. Decrease in circulation and perfusion to the fetus.

D. Decrease in circulation and perfusion to the fetus.

RN is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in this client? A. Diffuse abdominal cramping B. Rupturing of fetal membranes C. Start of regular contractions D. Dilation of cervix diameter to 10 cm.

D. Dilation of cervix diameter to 10 cm.

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client? A. Local infiltration B. Epidural block C. Regional anesthesia D. General anesthesia

D. General anesthesia

RN is reviewing postpartum nutrition needs with a group of new mothers who are breastfeeding their newborns. Which of the following statements by a member of the group indicates an understanding of the teaching? A. I'm glad I can have my morning coffee B. I should take folic acid to increase my milk supply C. I will continue adding 330 calories per day to my diet D. I'll continue my calcium supplements because I don't like milk

D. I'll continue my calcium supplements because I don't like milk

A 28 y/o client in her first trimester of pregnancy reports conflicting feelings. She expresses feeling proud and excited about her pregnancy while at the same time feeling fearful and anxious of its complications. Which action should the nurse do next? A. Schedule the client a consult with a psychiatric health care provider. B. Determine if the client's significant other is experiencing similar feelings about the pregnancy. C. Provide the client with information about pregnancy support groups. D. Inform the client that this is a normal response to pregnancy that many women experience.

D. Inform the client that this is a normal response to pregnancy that many women experience.

Pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which to be an advantage of adopting a kneeling position during labor. A. It helps the woman in labor save energy B. It facilitates vaginal exams. C. It facilitates external belt adjustment. D. It helps to rotate fetus in a posterior position.

D. It helps to rotate fetus in a posterior position.

RN in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency? A. Iron deficiency anemia B. Poor bone formation C. Macrosomic fetus D. Neural tube defects

D. Neural tube defects

During a prenatal visit, a client in her 2nd trimester verbalizes positive feelings about the pregnancy and conceptualizes the fetus. Which is the most appropriate nursing intervention when the client expresses such feelings? A. Encourage the client to focus on herself, not on the fetus. B. Inform the PCP about the client's feeling C. Inform the client that it is too early to conceptualize the fetus. D. Offer support and validation about the client's feelings.

D. Offer support and validation about the client's feelings.

RN is reviewing a new Rx for iron supplements with a client who's in the 8th week gestation and has iron deficiency anemia. Which of the following beverages should the RN instruct the client to take the iron supplements with? A. Ice water B. Low-fat or whole milk C. Tea or coffee D. Orange juice

D. Orange juice