Final

A pregnant client at 23 weeks' gestation asks the nurse, "What is a doula?" Which statement should the nurse make?

"A doula is a person trained in birth who provides emotional and physical support."

The nurse is completing the teaching for a newly pregnant client with a BMI of 23. Which statement by the client indicates an understanding of weight gain during this pregnancy?

"I need to gain 25 to 35 pounds (11 to 16 kg) during this pregnancy."

The parents of a 6-year-old male with idiopathic thrombocytopenic purpura (ITP) ask the nurse conducting an assessment of the child what causes the disease. What is the nurse's best response?

"ITP is primarily an autoimmune disease in that the immune system attacks and destroys the body's own platelets, for an unknown reason."

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?

"The temperature of the water should be at least 105℉ (40.5℃)."

The nurse is assessing children in an ambulatory clinic. Which child would be most likely to have iron-deficiency anemia?

A 15-year-old girl who has heavy menstrual periods

What is the most effective way to stimulate circulation after cesarean birth?

Ambulation within 4 hours of birth

The caregivers of a child with juvenile idiopathic arthritis are asking the nurse about exercise for their child. The nurse explains to the caregivers that gentle daily exercise is needed to prevent which condition from occurring?

Ankylosis

The nurse is preparing to assess the nutritional status of a patient who is 8 weeks pregnant. What is the most effective way for the nurse to assess the patient's food intake thus far in the pregnancy?

Ask the patient to describe intake for the last 24 hours

A nurse is reading a journal article about childbirth and the role of doulas in childbirth. The nurse demonstrates understanding of the article when the nurse identifies which activity as a function of a doula?

Caring for the mother's emotional needs

A nulliparous client at 37 weeks gestation calls the labor and delivery unit to report she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions?

Contraction, regular and lasting longer and stronger

The nurse is caring for a child admitted to the emergency center in diabetic ketoacidosis. Which clinical manifestations would the nurse most likely note in this child?

Drowziness and fruity odor to breath

The nurse is educating a pregnant woman and her partner to trace a pattern on her abdomen with her fingertips as a distraction method during contractions. What type of distraction method is this considered?

Effleurage

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at zero station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?

Engagement

The child with nephrotic syndrome who has ascites and difficulty breathing is probably most comfortable sleeping in which position?

Fowler's

The type of fracture often seen in young children is one in which there is not complete ossification of the bone, and the bone bends and just partially breaks. What type of fracture is this?

Greenstick

A pregnant client and her spouse come to the clinic to discuss options available for the labor and birth of their child. What should the nurse encourage clients to do in preparation for the birth of their child?

Have the couple write out a birth plan to better meet their needs during labor and delivery

A 9-month-old boy with iron-deficiency anemia is given ferrous sulfate therapy. Which assessment would best help you determine that he is actually taking it daily?

His stools will appear black.

The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true?

Late decelerations

The nurse is caring for a neonate who has undergone an intestinal pull-through procedure for an imperforate anus. Which action would be most important for the nurse to do postoperatively?

Listening for bowel sounds

A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in his care should be given priority?

Maintaining a fluid intravenous line

A patient is experiencing dysfunctional labor that is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this patient?

Oxytocin therapy

What finding would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure?

Projectile vomiting

The nurse is caring for a preschool-age child recovering from a lumbar puncture. What should the nurse do to ensure the patient does not develop a spinal headache?

Take the pillow away and have the patient lie flat in bed.

A 14-year-old girl is diagnosed as having scoliosis. When doing scoliosis screening with her, an important observation would be to note:

her posterior spine when she bends forward.

Untreated hyperemesis can lead to preterm birth. What is the cause of the preterm birth?

severe dehydration resulting in hypoperfusion of the placenta

In understanding the gastrointestinal system, the nurse recognizes that this system includes the stomach and intestines as well as:

the pharynx and esophagus.

Which of the following medications would the nurse be least likely to administer to a patient about to undergo a Cesarean delivery to prepare her gastrointestinal tract?

Castor oil

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?

Fetal lie

The nurse is providing discharge teaching to an adolescent who has been treated for pelvic inflammatory disease (PID). What would the nurse include as a preventive measure?

Insisting that sexual partners use condoms

The nurse is caring for an 8-year-old girl in traction. She has been in an acute care setting for two weeks and will require an additional 10 days in the hospital. She is showing signs of regression with thumb sucking and pleas for her tattered baby blanket. What would be the most helpful intervention?

"Let's ask your mom to bring your friends for a visit."

A child diagnosed with acute glomerulonephritis will most likely have a history of:

recent illness such as strep throat.

A school-age child is seen in the family clinic. The parents ask the nurse if their child should start taking growth hormones to help the child grow because the parents are short. Which of the following is the best response by the nurse?

"Research shows that there must be a diagnosis of deficiency before growth hormones can be started at this age."

The nurse is teaching a group of nursing students about acute glomerulonephritis genitourinary conditions. A student asks the about a condition that occurs when there is a decreased volume of urine output. The condition the student is referring to is:

oliguria.

The nurse is preparing a client for administeration of prostaglandin E2 to prepare for induction of labor. The nurse should explain this is administered via which route to the client?

Vaginal

The nurse is reinforcing discharge teaching with the caregivers of a child who is going home after a cast has been applied. The nurse explains to the caregivers that which issues should be reported if they occur or are seen related to this child? Select all that apply.

Drainage from under the cast Looseness of the cast on the extremity A foul odor under the cast Any area on the cast that is warm to the touch

For the past 18 hours, the client has been progressing slowly in labor in spite of various attempts to encourage the labor. The health care provider decides a cesarean delivery is necessary to ensure the well-being of both the mother and fetus. The nurse should point out to the client that this is due to which situation?

Dystocia

The nurse is discussing genitourinary conditions with a group of 16-year-old girls. One of the girls says she has heard about girls who have stopped taking birth control pills and now don't have periods. The condition the girl is referring to is:

amenorrhea.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

diabetes

The nurse is caring for a child with type 1 diabetes mellitus. The nurse notes that the child is drowsy, has flushed cheeks and red lips, a fruity smell to the breath, and there has been an increase in the rate and depth of the child's respirations. The nurse recognizes that these symptoms indicate the child has:

diabetic ketoacidosis.

The nurse has admitted a child with a diagnosis of severe gastroenteritis. To help prevent the risk of transmitting infection to other clients, the nurse should:

follow standard precautions.

A 15-year-old boy comes to the emergency department accompanied by his parents. The boy reports an abrupt onset of sudden pain on the right side of his scrotum. When asked to rate his pain on a scale of 1 to 10, with 10 being the most severe, the boy states, "It's a 12." Further assessment reveals a blue-black swelling on the affected side. The nurse suspects testicular torsion and immediately notifies the physician because:

the condition is a surgical emergency.

A pregnant woman is considering a home birth. Which statement by the woman would lead the nurse to determine that the woman is a good candidate for this birth setting?

"I'm interested in learning as much as I can about birth and what I need to do."

A pregnant woman at the clinic tells the nurse that her goal is to not take any medications during labor. What is the nurse's best response to this patient?

"The ultimate goal of childbirth is a healthy baby and healthy parents. Sometimes medication is necessary."

A 15-year-old is diagnosed with mettelschmerz and spotting. The teen is upset about the diagnosis, stating, "I think I have appendicitis or something else." What is the best response by the nurse?

"You seem very upset. Is something else worrying you?"

An important nursing intervention to institute with an infant prior to surgery for a Wilms' tumor is to place a sign over his crib that reads:

"do not palpate abdomen."

A 13-year-old girl tells the nurse during a gynecological visit that a friend of hers developed toxic shock syndrome from tampon use. The client says that tampons work well for her, but she wonders whether they are safe. Which of the following recommendations should the nurse give this client to help prevent toxic shock syndrome?

Alternate use of tampons with sanitary pads

A woman has just entered the recovery room after cesarean birth of a baby weighing 9 lb 14 oz. After connecting the client to the blood pressure monitor, it is noted her HR is 120 and BP is 80/40. What nursing action should be a priority?

Assess for bleeding

A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?

Assess for labor progression.

The nurse is observing a group of children diagnosed with various types of cerebral palsy. One of the children has an awkward and wide-based gait. The nurse recognizes this characteristic as common in which type of cerebral palsy?

Ataxic cerebral palsy

A nurse is instituting neutropenic precautions for a child. What information would the nurse most likely include? Select all that apply.

Avoiding rectal exams, suppositories, and enemas Discouraging fresh flowers in the child's room Placing a mask on the child when outside the room

A 17-year-old is found after a high school football game wandering around. He is confused, sweaty, and pale. Which test is most likely to be performed first?

Blood glucose level

Erin, a 19-year-old first-time mother in the second stage of labor who has been given an epidural, reports severe, unrelenting abdominal pain and rates it as 10 on a scale of 0 to 10. What should the nurse do?

Call the obstetrician; severe unrelenting abdominal pain could indicate placental abruption, uterine rupture, or other undiagnosed complication.

A 13-year-old adolescent is seen in the office and appears very anxious. For the past 2 weeks, the adolsecent has had some muscle twitching; upon examination, the client is found to have a positive Chvostek's sign. Which would be an appropriate explanation of Chvostek's sign?

Chvostek's sign is a facial muscle spasm demonstrated by tapping the facial nerve.

Antibiotic therapy to treat meningitis should be instituted immediately after which event?

Collection of cerebrospinal fluid (CSF) and blood for culture

A child needs to collect urine for 24 hours and the nurse explains that this test assesses glomerular filtration rate and how the kidneys are functioning. What would be indicative of this type of test?

Creatinine clearance

A 4-year-old diagnosed with diabetes insipidus is being discharged. Which information below is most important to emphasize to the parents?

Diabetes insipidus is different from diabetes mellitus.

The nurse is observing a 3-year-old boy who is sitting and playing in the waiting area of his pediatrician's office. The nurse calls the boy and his mother back for the boy's appointment. The boy rolls onto his stomach and pushes himself to his knees. Then he presses his hands against his ankles, knees, and thighs, walking up the front of his body, to stand. Which condition should the nurse suspect in this client?

Duchenne muscular dystrophy

At which time in a client's labor process would the nurse encourage effleurage?

During the early labor phase

After learning about the need for a cesarean birth, the pregnant patient begins to cry and hyperventilate. Which nursing diagnosis should the nurse use to guide the care that the patient needs at this time?

Fear related to impending surgery

In providing culturally competent care to a laboring woman, which is a priority?

Identify how the client expresses labor pain.

The nurse is teaching a prenatal class about a cesarean delivery. What benefit of a low transverse uterine incision should the nurse point out in the teaching?

Least likely to rupture during subsequent labors.

Nursing students are reviewing information about childhood cancers. They demonstrate understanding of the information when they identify what as the most frequent type?

Leukemia

A client in her second trimester of pregnancy arrives at a health care facility reporting heartburn. What instructions should the nurse offer to help the client deal with heartburn? Select all that apply.

Limit consumption of food before bedtime. Sleep in a semi-Fowler's position. Avoid overeating.

A father brings his 10-year-old daughter in to the physician's office with jaundice, headache, fever, and anorexia, symptoms she has had for the past few days. The nurse should suspect infection of which organ in this client?

Liver

The nurse has developed a plan of care for a 12-month-old hospitalized with dehydration as a result of rotavirus. Which intervention would the nurse include in the plan of care?

Maintaining the intravenous (IV) fluid rate as ordered

After pelvic measurements, a patient who is 20 weeks' pregnant is informed that the diagonal conjugate diameter is narrow. For which component of labor should the nurse plan care to address this?

Passageway

The nurse is examining a 7-year-old with suspected appendicitis. Which physical findings would indicate the possibility of appendicitis?

Persistent, right lower quadrant pain with rebound tenderness

A nurse recommends to a couple, who are soon to be parents that they attend early prenatal classes. Which of the following topics would be covered in an early prenatal class?

Physical and emotional changes of pregnancy

The nurse is interviewing the caregivers of a child admitted with a diagnosis of type 1 diabetes mellitus. The caregiver states, "The teacher tells us that our child has to use the restroom many more times a day than other students do." The caregiver's statement indicates the child most likely has:

Polyuria

The nurse is preparing a client for an emergent cesarean delivery. Which action should the nurse prioritize?

Sign informed consent.

The nursing instructor is conducting a session exploring the various factors related to induction of labor. The instructor determines the session is successful after the students correctly choose which factors are used to determine if the cervix is ripe enough for induction?

Station, effacement, cervical consistency, dilatation, and cervical position

At a prenatal appointment, a woman who is 3 months pregnant confides to you that she ingests starch because of a craving she has had since adolescence. She is now 26 years old. What would be your most appropriate response?

Suggest she have a hemoglobin assessment done because of the association between pica and iron-deficiency anemia.

To prevent further urinary tract infections in a preschooler, what measures would you teach her mother?

Teach her to wipe her perineum front to back after voiding.

When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply.

The nurse stays with the child and calls for help when a seizure begins. The nurse pads the crib or side rails before a seizure. The nurse positions the child on the side during a seizure. The nurse teaches the caregivers regarding seizure precautions. The nurse has oxygen available to use during a seizure.

A child is having their urine checked for complaints of polyuria. When analyzing the results, what would positive glucose indicate?

This determines the presence of sugar in the urine.

The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging?

Use McRoberts maneuver.

The nurse is teaching about an iron supplement that client is going to take every day. The nurse teaches the client to take the iron supplement with which type of fluid?

citrus juice

A nursing student learning about childbirth preparation in a maternity course correctly identifies which of the following to be a major determinant of the plans women make for childbirth?

culture

The nurse is caring for a child diagnosed with a urinary tract infection. The caregiver asks the nurse why it is so important for the child to have so much fluid. The nurse tells the caregiver that the most important reason the child needs increased fluids is to:

dilute the urine and flush the bladder.

A 5-year-old child is at the pediatric clinic for a well-child visit. Which symptom alerts the health care provider that this child might have acute lymphocytic leukemia?

lethargy, bruises, and lymphadenopathy

A 7-year-old girl is seen in the clinic for a sports physical. Upon assessment the nurse notices pubic hair and increased breast tissue in both breasts. What should the nurse suspect?

precocious puberty

A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?

respiratory depression

A nurse should recognize that which symptom would be most consistent with a diagnosis of candidiasis?

thick, white discharge