Maternal Final

A woman arrives at the clinic for a pregnancy test. The first day of her last menstrual period (LMP) was May 13, 2017. Her expected date of birth (EDR) would be?

February 20, 2018

An 8 year old child presents with a diagnosis of sickle cell anemia. The child is hospitalized and the nurse recognizes which of the following as the initial nursing intervention.

Hydration and pain management

During a routine well child check, an 8 year old child is having her visual acuity assessed. She reports that her vision is blurry at a close range and clear at a far range. Which of the following diagnoses is consistent with these symptoms?

Hyperopia

A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting therapeutic management of this child will begin with which nursing intervention

IV fluids

Which fluid should the nurse offer to help keep a post tonsillectomy child orally hydrated?

Ice chips

A preadolescent client, a member of a single parent family has abdominal pain and the healthcare provider suspects that an appendectomy might need to be performed. The patient's father is asking for a second opinion, whereas the mother tells the nurse to be done to help the patient. What does the nurse need to assess before moving forward with panning care for this patient?

Identify the custodial parent

The nurse is caring for a newborn diagnosed with patent ductus arteriosus. Which finding will the nurse assess that is consistent with this diagnosis.

Machine like murmur heard at the left sub clavicular margin

A 7 year old is diagnosed with osteomyelitis. Which of the following would you anticipate as a primary nursing intervention to include in the child's plan of care?

Maintaining intravenous antibiotic therapy

During an assessment, the nurse determines that a 3 month old baby has a moro reflex. What does this finding to indicate to the nurse?

Most 3 month olds still have a moro reflex

Management of primary dysmenorrhea often requires a multifaceted approach. The nurse who provides care for a client with this condition should be that the optimal pharmacological therapy for pain relief is.

NSAIDs

Parents ask the nurse why their premature infant is receiving a feeding through the mouth rather than the nose. What is the best explanation by the nurse?

Newborns are obligate nose breathers so nasogastric may obstruct their breathing

The nurse in the pediatric clinic is providing teaching to the family of a 1 month old infant with gastroesophageal reflux. Which of the following will be included in the teaching?

Position upright for 30 minutes after feedings

An adolescent client delivers a 9 lb baby after being in labor for 20 hours. During the immediate postpartum period, which potential complication is the highest priority for the nurse to assess for?

Postpartum hemorrhage

A terminally ill child is awake at 2 am and continues to put on the call light. What should the nurse do regarding the child's behavior?

Sit with the child until sleep comes

An infant is prescribed digoxin. The nurse teaches the parents that the action of digoxin is to do which of the following?

Slow and strengthen her heartbeat

A 6 month old girl is diagnosed as having atopic dermatitis. When interviewing her parents, they describe the following care measures. Which one would lead you to think more healthy teaching is needed?

To dry lesions, the father applies alcohol to lesions daily.

The nurse on the pediatric unit is caring for a child admitted for epiglottitis. Which of the following would be appropriate positioning for the patient?

Upright

The nurse is concerned that a pregnant patient is using cocaine. What should the nurse suggest to the healthcare provider to confirm this suspicion?

Urinalysis

Prenatal Testing is done to identify health issues that may interfere with the developing fetus. During which time frame would the nurse expect the 1 hour glucose tolerance test to be ordered on a healthy primigravida?

24-28 weeks gestation

Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant. This is her 4th pregnancy. She gave birth to one baby vaginally at 25 weeks who died, experienced a miscarriage, and has one living child who was delievered at 38 weeks gestation.

4 1 1 1 1

At 1 minute after birth the nurse assesses the infant and notes: heart rate of 120 beats/min, strong flexion of extremities, a strong cry, active grimacing and a pink body but blue extremities. The nurse would calculate an Apgar score of which number for this infant?

9

Which personal protective equipment will the nurse wear while inserting a urinary catheter on a child positive for HIV and tuberculosis? (SATA)

-Sterile gloves -N-95 respiration -Disposable gown -Protective eye shield

After an hour of oxytocin therapy, A laboring patient experiences contractions that last for a duration of 90 seconds occurring at a frequency of every 2 minutes. What priority action should the nurse take?

-Stop infusion -Lay on left side

A toddler who has Kawasaki disease (KD) is admitted to the pediatric unit. Which of the following findings should the nurse expect to observe during the physical assessment? (SATA):

-Strawberry tongue -Edema for hands and feet -Conjunctivitis without exudate

The nurse should expect the anterior fontanel to close at what age?

12 to 18 months

The nurse in labor and delivery is monitoring a client at 38 weeks gestation who presents for a nonstress test (NST). In performing a non stress test, the nurse will observe for and document which of the following? (SATA)

-Accelerations in the fetal heart rate -Decelerations in the fetal heart rate -Variability in the fetal heart rate

A school nurse is preparing an educational presentation to a group of teens, parents, and teachers about how to prevent skin cancer. Which topics need to be included in the presentation? (SATA)

-Avoid getting a severe sunburn -It is important to avoid tanning beds -Sunscreen application needs to include tops of ears and back of neck -There is a direct association between two or more episodes of sunburn and development of malignant melanoma

During a routine well child visit, the mother of a preadolescent client asks the nurse to explain signs of sexual abuse. The mother is concerned because an older male neighbor has been making comments and overly admiring the child when playing outdoors. What signs of sexual abuse should the nurse tell the mother to look for? (SATA)

-Child reports abdominal pain -Child has a change in school performance -Child demonstrates anxiety or trouble sleeping -Child does not want to be left alone with a certain adult

The nurse is participating in a preschool health screening program. What are appropriate secondary health promotion activities? (SATA).

-Conduct vision tests -Conduct hearing tests -Review immunizations received

The nurse is instructing the mother of a school age child with a leg cast about cast care at home. What should the nurse include in this teaching? (SATA)

-Cover the cast with a plastic bag to bathe -Remind that nothing is to be put inside the cast -Use the cool setting on a hair dryer to ease itchy skin -Remain as active as possible with appropriate modifications

The nurse is concerned that a school-age child is developing pneumonia. What did the nurse most likely assess in this client? (SATA)

-Crackles (rales) -Elevated temperature -Productive harsh cough

The nurse is instructing an adolescent regarding sexual activity. What can the nurse include in her teaching? (SATA)

-Do not be influenced by friends to have sex -The only 100% effective method of preventing pregnancy is abstinence -Learn about safe sex practices

Nursing considerations for a patient with seizures, what precautions should we take?

-Don't stick anything in the airway -Move objects away -Safe environment -Stay with child -Patent airway

A 12 year old child has pyelonephritis. Which of the following would the nurse expect to observe when assessing the child? (SATA)

-Flank pain -Costovertebral angle tenderness -Fever

The student nurse is preparing education for the parents of a 6 year old that will begin iron supplementation following a diagnosis of iron-deficiency anemia. What should be included in the education? (SATA)

-Iron should be given with a glass of orange juice -Iron may cause black tarry stools -Iron may cause constipation

A nurse is caring for a school aged child recovering from an open reduction for a fractured femur. Which assessment findings indicate that the child is developing an infection? (SATA)

-Lethargy -Increased pulse rate -Increased body temperature

The mother of a school age child is distraught because this child has been diagnosed with obesity. What teaching will the nurse provide to the family regarding achieving the goal of BMI within normal range? (SATA)

-Maintain a balanced eating approach in the home -Encourage participation in a new sport in which the child has an interest -Encourage increased activity such as walking the dog after school

The nurse teaches a 14-year-old child about the proper use of a metered dose inhaler to control asthma symptoms. Which teaching points should the nurse include in these instructions? (SATA)

-Shake canister before using -Hold breath for 5 to 10 seconds -Activate inhaler while taking a deep breath

The nurse is caring for an adolescent female after a sexual assault. She notes which of the following to be consistent with past traumatic stress disorder (PTSD)? (SATA)

-Sleep disturbances -Hypervigilance -Flashbacks -Withdrawal from family

A nurse is providing care to a 9 year old child who has fractured his left distal radius. Which of the following actions should be included in the plan of care for this patient? (SATA)

-Stabilize the injury -Elevate the arm -Assess neurovascular status

An infant weighed 6 pounds at birth. What is the expected weight in pounds at 1 year of age?

18 (triple)

The school nurse is observing in the classroom. The child is speaking, then suddenly stops and stares for about 5 seconds, and then continues speaking. The nurse charts this experience as what type of seizure?

Absence

A student nurse notes that the population of a sexually transmitted infection Health Clinic consists largely of teenagers. The nurse explains that adolescents are at a greater risk for contracting STIs because of which factor?

Adolescents are risk takers and believe they are invincible

A hospitalized 2 year old child with croup is receiving corticosteroid therapy and the mother asks why the provider did not prescribe antibiotics? What is the nurse's best response to the mother?

Antibiotics are not indicated unless a bacterial infection is the cause of the illness

A nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that her bandage is too wet. The nurse finds the bandage and bed soaked with blood. What is the most appropriate initial nursing action?

Apply direct pressure above the catheterization site

A newborn is diagnosed with coarctation of the aorta. Which assessment should the nurse make when caring for this infant

Assessing femoral and radial pulses simultaneously

Upon assessment of a 3-year-old who has been diagnosed with croup, the nurse notes stridor while the child is asleep. Which of the following interventions would the nurse expect to perform to the client?

Assisting with racemic epinephrine nebulizer therapy

A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory phase of respiration. What should this suggest to the nurse?

Asthma

The nurse visits the foster home of a newborn with failure to thrive syndrome. Which observation indicates a successful outcome for the child's care?

Child eagerly takes a bottle and is gaining weight

A nurse is reviewing discharge instructions with the family of a child diagnosed with a urinary tract infection. Which instruction should the nurse include with discharge teaching regarding medications?

Complete the entire course of antibiotics ordered by the provider.

Your client attempted suicide with a medication overdose. Which interventions would be most effective in preventing an adolescent from attempting suicide again?

Coordinate involvement of a mental health provider to allow children to express feelings

An 18 month old child is admitted with signs of increased intracranial pressure. What would the nurse observe when assessing this patient?

Decreased level of consciousness and decreased respiratory rate

The nurse is reviewing normal and abnormal changes in pregnancy with a woman who is 32 weeks pregnant. Which of the following abnormal changes should the nurse address first?

Decreased or absent fetal movement

The nurse notes that a child with a burn injury is prescribed daily debridement. What should the nurse instruct the child and parents about the purpose of the treatment?

Decreases risk for infection

An infant is brought to the emergency department with poor skin turgor, weight loss, lethargy, and tachycardia. What does the nurse suspect is the problem?

Dehydration

What is the most important observation the nurse should watch for in a newborn who has a salt-losing form of congenital adrenal hyperplasia?

Dehydration

The pediatric nurse is familiar with Kubler-Ross's stages of grief. Parents who are feeling confused and refusing to discuss the disease with any provider are in which stage of grief?

Denial

A 6-month-old infant is admitted to the hospital because of a fever. When you obtain a health history, what data would the nurse obtain first?

Details about the fever

A 6-year-old has a diagnosis of streptococcal pharyngitis. When planning care, the nurse evaluates the client's symptoms for which of the following dangerous outcomes?

Development of rheumatic fever

While caring for a child with bacterial pneumonia, the nurse examines the child's respiratory system. What is an expected assessment finding for bacterial pneumonia?

Diminished breath sounds and crackles (rales) noted with auscultation

A child is taking valproic acid for epilepsy. What important information should the nurse explain to the parents?

Do not discontinue the drug abruptly

The nurse is teaching a child with type 1 diabetes melitus to administer her own insulin. The child is receiving a combination of short-acting and long acting insulin. How will the nurse know that the child has appropriately learned the technique.

Draws up the short acting insulin into the syringe first

The triage nurse is assessing a patient who has presented to the emergency department with complaints of pain in the left lower leg and ankle after a fall. On assessment, the nurse notes swelling to the lateral aspect of the left ankle, point tenderness, and crepitus on palpation. The nurse plans care for the patient recognizing that this presentation is most consistent with which of the following injuries?

Fracture

The nurse is providing discharge teaching to the child and her family following inpatient treatment for anaphylaxis. Which of the following statements by the partners or family would indicate the need for more instruction?

If my symptoms resolve after injections, I should stay home and rest for the remainder of the day

The nurse in the cardiac clinic is caring for a new patient who has been referred to the clinic due to a new heart murmur heard by the pediatrician during the well child exam. What noninvasive diagnostic testing does the nurse expect the cardiologist to order first?

Echocardiogram

The nurse is caring for a chronically ill adolescent. The nurse recommends which of the following to prevent the pediatric client from feeling lonely.

Encourage friends to be available through social media.

An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to

Encourage parents to room in

A 5 year old child is placed in skeletal traction to immobilize a fracture. What is important for the nurse to encourage the parents to do with the child during immobilization?

Engage the child in therapeutic play while confined to this position

The nurse is instructing the parents of a child with sickle-cell anemia on safety precautions. What should the nurse emphasize during this teaching?

Ensure a consistent and daily intake of adequate fluids to prevent dehydration

The nurse in the newborn nursery is reviewing the physician's orders to prepare a 2 day old newborn for circumcision. Which of the following findings on assessment of this patient would be a contraindication to the procedure?

Epispadias

On assessment of a 3 year old toddler, the nurse notes that the left eye intermittently deviates medially. Mom confirms that she sees this often when the child is laughing or when she is tired. This finding is most consistent with which of the following?

Esotropia

The nurse is caring for a preschool age child who is aware of impending death. What behavior should the nurse expect the child to demonstrate at this time?

Fear of being separated from parents

A child is experiencing anaphylactic shock. Which provider order would the nurse complete first?

Give epinephrine IM

The parents of a child with acute glomerulonephritis ask the nurse to explain the cause of the disease. What organism should the nurse instruct the parents as being the cause for the disorder?

Group A beta hemolytic streptococci

A 24 year old G2P1001 presents to the office for her 36 week visit. Which of the following labs would the nurse expect the provider to order as routine scheduled testing?

Group B strep culture

Health teaching that the nurse would provide for parents of an immunosuppressed child focus on which important measure

Hand washing

The nurse is preparing to assess a toddler during a routine health maintenance visit. Which assessment will the nurse perform to determine the child's growth milestone?

Height and weight

The nurse is caring for a preschool aged child who needs a computerized tomography (CT) scan. Which action would the nurse use to --it prepare the child for this diagnostic test?

Help the child to pretend that the CT scan machine is a camera

A toddler insists on brushing his own teeth and dressing himself. What advice would you give his parents regarding this?

Helping with his own cares allows him to experience autonomy

The nurse assesses that a fetus is in a breech presentation. Where would you auscultate for fetal heart sounds?

High in the abdomen

Which statement by the nurse is most likely to gain the cooperation of a young child?

If you take this medicine, I can get you a popsicle

A 3 month old is admitted to the hospital for failure to thrive. Which of the following are indications of failure to thrive in a 3 month old infant?

Infant falls below 5% in growth percentile

The nurse is caring for a 10-year-old child with growth hormone deficiency. Which therapy would you anticipate being prescribed for the child?

Injections of growth hormone

A 4 year old child with a urinary tract infection is scheduled to have a voided cystourethrogram. What would a nurse do to prepare for the child for this procedure?

Insert Foley catheter for instillation of contrast

A nurse is caring for a client who is in the first stage of labor with a report of ruptured membranes prior to admission to the labor unit. The nurse observes the fetal heart rate changes baseline from 150/min to 110/min. During a vaginal exam, the nurse notes a pulsation at the cervix. Which of the following actions should the nurse perform first?

Insert a gloved hand into the vagina to lift the presenting part off of the cord

Shortly after delivery, a newborn is diagnosed with hypocalcemia/hypoglycemia. What manifestations will the nurse assess in this client?

Jitteriness

The nurse is assessing a child who has just been admitted to the hospital for observations after a head injury. What is the most essential part of the nursing assessment to detect early signs of a worsening condition?

LOC

A nurse is caring for a client who is at 36 weeks of gestation and who had a suspected placenta previa. Which of the following findings support this diagnosis?

Painless bright red vaginal bleeding

A nurse is caring for an adolescent who has a newly applied fiberglass cast for a fractured tibia. Immediately following application of the cast, the nurse should recognize that the priority nursing action is to do which of the following?

Perform a neurovascular assessment

A patient in labor with chronic back pain tells the nurse about taking a dose of hydrocodone/acetaminophen (Vicodin) for labor pain prior to coming to the hospital. What should the nurse prepare to do after the fetus is delivered?

Perform ongoing assessment of the infant for withdrawal symptoms after delivery

A 5 month old infant is brought to the emergency department with a reported history of fever, nasal drainage, and cough. Over the past day, the mom reports that the patient has demonstrated coughing spells that are followed by a grasp or whoop. The nurse recognizes that these symptoms are most consistent with which of the following illnesses?

Pertussis

The nurse is caring for an 18 month old with bronchiolitis in the emergency room. Which of the following would be included in discharge teaching for the family?

Place a cool mist humidifier in his room

What should the nurse teach the parents of a child with tetralogy of fallot to do if the child suddenly becomes cyanotic and disconnect

Place in a knee chest position

A woman is 39 weeks gestation with severe abdominal pain that remains constant. She is being admitted to the labor and delivery unit. She suddenly experiences increased contraction frequently for every one to two minutes, has dark vaginal bleeding, and a rigid abdomen. What should the nurse expect at this time?

Placenta abruption

A nurse is caring for a child who is experiencing a generalized tonic/clonic seizure. Which of the following is the priority action for the nurse to take?

Position the child in a side lying position

Which technique should the nurse use to administer eardrops to a 4-year-old child?

Pull the pinna up and back

A child in kidney failure has had a kidney transplant. What should the nurse include in the teaching regarding postoperative care?

Reduce socialization for infection control precautions

The nurse is planning care for a preschool age child diagnosed with meningitis. What should the nurse identify as a priority goal for this patient's care?

Reduce the pain related to nuchal rigidity.

A nurse in an emergency situation is caring for a child with a superficial burn of the foot. Which of the following is the immediate priority?

Relieving pain and discomfort

The nurse is preparing to administer blood products to the pediatric client. Which of the following reflects safe practice in administration of blood products?

Remain with the patience for the first 15 minutes of the infusion

A nurse performs an admission assessment on a child and suspects physical abuse. Based on the suspicion, the primary legal nursing responsibility is to do which of the following?

Report the case in which the abuse is suspected to the local authorities and your supervisor or charge nurse

What education should a nurse provide to a parent to help their child complete Erikson's developmental task during the infant period?

Respond to the child's needs consistently

The nurse obtains a stool specimen for ova and parasites. Which of the following is the responsibility of the nurse?

See that it arrives at the laboratory promptly

A 7 year old child is brought to the emergency department for evaluation of a burn injury. On exam, the nurse notes large, ruptured blisters and a white or pale color ONLY SAYS RED/PINK to the injured tissue. The patient is in extreme pain. The most damaged part of this burn is consistent with a burn depth of:

Superficial partial thickness (2nd degree)

A nurse in the newborn nursery is monitoring a newborn infant for respiratory distress syndrome. Which assessment signs, if noted in the newborn, would alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

The nurse is caring for an 8 month old baby diagnosed with spastic cerebral palsy. Which assessment finding supports this medical diagnosis?

The child has a strong Moro reflex when startled

The nurse is planning teaching for the parents of a child with Legg-Calve-Perthes disease. What should the nurse emphasize when conducting this teaching?

The child may have a non-weight bearing period

The nurse evaluates teaching provided to a school-age child and parents about the medication pancrelipase for cystic fibrosis. Which observation indicates that teaching has been effective?

The child takes a dose before having an afternoon snack

During a physical assessment, a 15 year old male expresses concern about being short in height. Which should the nurse respond to his clients concern?

The epiphyseal lines of long bones close by 18 to 20 years of age in males.

The nurse is visiting the home of a previous history of physical neglect. Which observation indicates that interventions have not been successful?

The father allows the children to stay home from school whenever they desire.

The nurse is evaluating outcomes about a family's ability to care for an adolescent child who is recovering from a spinal cord injury. Which statement indicates that the family is transitioning in a healthy manner?

The mother and father state the ability to provide care for the child is becoming easier.

A 4 year old has developed acute lymphocytic leukemia (ALL) for which of the following reasons does the nurse take axillary, rather than rectal temperatures?

The rectum is highly vascular and rectal temps would result in trauma to the tissue which may bleed easily or cause painful bruising

After cardiac surgery, a child has chest tubes inserted that are attached to an under water seal drainage system. When should the nurse be prepared to clamp chest tubes.

The tube becomes disconnected

The mother of a child having myringotomy tubes placed asks, "Will my child lose hearing while the tubes are in place?" What is the nurses best answer?

The tubes are inserted into a section of eardrum in which the hearing is not affected

A school age child is diagnosed as having Cushing syndrome from a long term therapy with oral prednisone. What assessment finding is consistent with this child's diagnosis and treatment?

There are purple striae on the abdomen

A parent of a school-aged child is distressed to learn of the child is diagnosed with type 2 diabetes mellitus. The parent asks the nurse how this could happen because no one in the family has diabetes. Which response is most accurate?

This disorder is associated with metabolic disturbances that result in insulin resistance

A 7 year old child presents to the pediatric clinic with a reported history of low grade fever followed by the development of a rash. On assessment the nurse notes multiple red papules, vesicles, and crusted lesions scattered over the trunk, face, and extremities. What disease/disorder would the nurse expect the client is exhibiting?

Varicella (chicken pox)

A 4 year old child is being prepared to undergo a bronchoscopy to remove an aspirated pea. Which statement by the parent would the nurse determine the need for further teaching?

We will be able to take our child home immediately after the procedure is completed

A 7 year old child is diagnosed with type 1 diabetes. What is one of the first symptoms noticed by parents when this illness develops in the child?

Weight loss

Which statement would indicate that the client requires additional instruction about breast self examination?

Yellow discharge from my nipple is normal if I am having my period.

The pediatric nurse is assessing a 4 month old infant in the clinic. The child's mother explains that they recently visited a theme park and afterward had learned that there had been four cases of measles diagnosed in children who had visited the park on the same day. When providing education to the mother regarding how she can protect her child from measles infections, the most appropriate statement for the nurse to make is which of the following?

Your daughter will be able to receive the measles vaccine after 12 months of age

The clinic is providing a federally approved car seat to an infant's family. The nurse should explain that the safest place to install this car seat in the vehicle is

rear facing in the back seat