OB & Peds
A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide?
Breastfeed the infant every 2 hours
The nurse has provided teaching about home care management for the parents of a child diagnosed with cystic fibrosis. Which statements by the parents indicate a need for further teaching? Select all that apply.
Bronchodilator breathing treatment should be given right after chest physiotherapy. Pancreatic enzy,es should be administered every morning and evening. We will prohibit our child from participating in sports activites.
A child, age 15 months, is admitted to the health care facility. During the initial nursing assessment, which statement by the mother most strongly suggests that the child has a Wilms' tumor?
"My child's abdomen seems bigger, and his diapers are much tighter"
A nurse is conducting an examination of a 6-month-old baby. During the examination, the nurse should be able to elicit which reflex?
Babinski's
When assessing a child's cultural background, the nurse in charge should keep in mind that:
Behavioral patterns are passed from one generation to the next
A patient has gestational diabetes and is currently 34 weeks pregnant. Which assessment findings below should you immediately report to the physician? Select all that apply:
Blood Pressure 190/102 Proteinuria
The nurse is assessing a 7 -day- old infant at home. The infant is breastfeeding, and the mother is concerned about whether the baby is receiving breastmilk during the feedings. Which question is most important for the nurse to ask the mother, when assessing the infant's breastmilk intake?
Do you hear swalloing noises while the baby is nursing
The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider?
Exhibits a sudden and unexplained weight gain
A client who's gravida 2 at 32 weeks gestation with elevated blood pressure has been taught about the danger signs to report. Which of the following statements would demonstrate that she understands when she should call the health care provider's office? Select all that apply.
If i see any bleeding even if I have no pain. If I have a pounding headache that doesnt go away. If the baby seems to be more active than usual.
Within minutes of giving birth to a healthy infant, the client displays symptoms of respiratory distress. An amniotic fluid embolism is suspected. In addition to respiratory distress, for what other complication should the nurse assess the client?
Uncontrolled bleeding
The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching?
I can start doing abdominal exercises as soon as I get home
The nurse is caring for an adolescent who had an external fixator placed after suffering a fracture of the wrist during a bicycle accident. Which statement by the adolescent would be expected about separation anxiety?
I hope my friends don't forget about visiting me
You're assessing a 4 year old with epiglottitis who just arrived to the pediatric clinic. The child is drooling and has a respiratory rate of 45 breaths per minute. In addition, the child is becoming increasingly apprehensive. Which findings below exhibited by the patient represents an acute upper airway obstruction that requires IMMEDIATE treatment? Select all that apply:
Stridor. Cyanosis. Chest retractions. Nasal flaring
The nurse received report on the following children on the inpatient pediatric unit. Which child should the nurse assess first?
3- year-old with newly diagnosed asthma, with dimished right lower lobe breath sounds
A nursing instructor is reviewing the menstrual cycle with a nursing student who will be conducting a prenatal teaching session. The instructor asks the student to describe the FSH and LH. The student accurately responds by stating that:
FSH and LH are secreted by the anterior pituitary gland
A toddler develops acute otitis media and is ordered cefpodoxime proxetil (Vantin) 5 mg/kg P.O. every 12 hours. If the child weighs 22 lb (10 kg), how many milligrams will the nurse administer with each dose?
50 mg
When performing newborn resuscitation, which action would the nurse do first?
Administer epinephrine intavenously
The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid. Select all that apply.
Allows for fetal movement. Surrounds, cushions, and protects the fetus. Maintains the body temperature of the fetus. Can be used measuere fetal kidney function.
A nurse is reviewing her shift assignment. Which child should she assess first?
An 11-month-old infant receiving chemotherapy through a central venous catheter
Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
An alternate method of birth control is needed when taking antibiotics
The nurse is managing care of a primigravida at full term who is in active labor. What should be included in developing the plan of care for this client?
Anesthesia/pain level assessment every 30 minutes
A 5 year old girl is recently diagnosed with Kawasaki Disease. Which of the following is she at risk for developing?
Aneurysm formation
A client is to be discharged with her newborn, who was just circumcised. The nurse is planning discharge instructions about postcircumcision care. What should be included?
Apply diapers loosely
A nurse is caring for a client following delivery of a stillborn infant. Which actions should the nurse take? Select All That Apply
Ask the parents if they would like to help bathe the infant. Encourage the parents and family members to hold the infant. Offer to obtain handprints, footprints and photographs of the infant.
A nurse is collecting data during an admission assessment of a client who is pregnant with twins. . The client has a healthy 5-year-old child who was delivered at 38 wks and tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as:
G2, T1, P0, A0, L1
Which of the following is a probable sign of pregnancy?
Goodell's sign
The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage?
Infant birth weight of 9lb and 2oz
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviewes the child's record and expects to note which symptom of this disorder documented?
Jelly-like stools with mucus
A client arrives at the clinic for the first prenatal assessment. The client tells a nurse that the first day of her LMP was October 19, 2012. Using Naegele's rule, the nurse determines the EDD is
July 26, 2013
A nurse is reviewing a care plan for an adolescent girl who's receiving chemotherapy for leukemia who was admitted for pneumonia. The adolescent's platelet count is 50,000 μl. Which item in the care plan should the nurse revise? SATA
Keep a sign over the bed that reads "No needle sticks and nothing per rectum" Administer oxygen at a rate of 4 L/minute using a nonhumidified nasal cannula
The nurse is caring for a hospitalized child with leukemia, experiencing bone marrow depression from chemotherapy. The nurse should contact the health care provider to question which prescribed medication?
MMR vaccine
A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit?
Monitor for fetal movement
A client's membranes rupture, and the nurse immediately detects the presence of a prolapsed umbilical cord. The nurse alerts another nurse, who calls the primary healthcare provider. Place the following interventions in the order in which they should be performed.
Moving the presenting part of the cord. Placing the client in the Trendelingburg position. Administering oxygen by facemask. Check the fetal heart rate.
A 6 month old infant, diagnosed with hydrocephalus, is recovering from surgery to place a shunt. Which of the following should the nurse instruct the parents regarding the client's care?
Notify the physician if the client demonstrates malaise or irritability
The nurse is providing discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the health care provider?
Pain, redness, or swelling in the breasts
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80mmhg to 90/60 mm hg. Which action should the nurse take immediately?
Place the client in a lateral position
Before surgery to remove an ectopic pregnancy and the fallopian tube, which signs or symptoms would alert the nurse to the possibility of tubal rupture?
Prophuse sweating
The mother of a child with type 1 diabetes mellitus asks why her child cannot avoid all those "shots" and take pills as an uncle does. The most appropriate response by the nurse is
Your child needs to have insulin replaced, and the oral hypoglycemics only add to an exisiting supply of insulin
A nurse is teaching an adolescent with inflammatory bowel disease about treatment with corticosteroids. Which adverse effects are concerns for this client? Select all that apply
acne hirsutism mood swings osteoporosis adrenal suppression
When administering morphine to a school-age child, which sign or symptom should cause the nurse to be concerned?
anemia
A 40 week gestation primigravada client is being induced with an oxytocin (pitocin) secondary infusion and complains pain in her lower back. Which intervention should the nurse implement?
apply firm pressure on the sacral area
A 3 year old arrives to the ER. The child has a temperature of 102.4 'F, respiratory rate of 45, and is agitated. The child is diagnosed with epiglottitis. You note the child is sitting up, positioned forward with chin in the air and the tongue is protruding with the mouth open. Which nursing intervention below is NOT appropriate for this patient?
asssist the patient in supine position
A nurse is teaching a parent of a school-age child about signs and symptoms of fever that require immediate notification of the physician. Which description should the nurse include?
complaints of a stiff neck
The nurse assessing a child admitted to the pediatric floor for dehydration observes that the child has varicella lesions. Which nursing intervention has the highest priority?
implement airborne precautions
An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder?
metabolic alkalosis
While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should:
notify the doctor
An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note:
ortolani's sign
A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for.
periods of fetal movement followed by quiet periods
A client is admitted with a marginal placenta previa. Which item should the nurse have readily available?
two units of typed and screened blood
The nurse caring for a child who is awake and alert in the post anesthesia care unit (PACU) immediately after a tonsillectomy should implement which interventions? Select all that apply
Observe for continuous swallowing. Administer prescribed oral pain medications/ Offer ice pops
The nurse is caring for an infant with bronchiolitis in the hospital pediatric unit. During breastfeeding, the nurse observes the infant's oxygen saturation decreasing from 95% to 92%. Which intervention should the nurse implement first?
Slightly increase oxygen flow through the nasal cannula and observe the infants response
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. Which assessment finding indicates to the nurse that the client is experiencing magnesium toxicity?
sudden drop in FHR
While feeding a 3 month old infant, who has Tetralogy of Fallot, you notice the infant's skin begins to have a bluish tint and the breathing rate has increased. Your immediate nursing action is to:
Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen.
A nurse is caring for a client in labor. When her cervix is 3-4 cm and 60% effaced and the vertex is -1 station, there is a sudden spurt of dark blood from the vagina. The uterus is irritable upon palpation and does not relax fully between contractions. What is the initial nursing action?
Assessing the FHR, uterine activity and blood pressure
An infant's parents ask the nurse about preventing otitis media. Which of the following should be recommended?
Avoid tobacco smoke
A 9-year-old boy with diabetes mellitus tests his glucose level in the nurse's office before lunch. According to this sliding scale of insulin, he's due for 1 unit of regular insulin. What steps should a nurse follow after confirming the medication order, washing her hands, drawing up the appropriate dose, verifying the boy's identity, and putting on gloves? Put the following steps in chronological order.
Select appropriate injection site with the child. Clean site with an alcohol pad; loosen needle cover. Pinch the skin around the injection site. Uncover needle; insert at 45-90 degree angle. Release the skin and give the injection. Cover the site with an alcohol pad.
An eight-month-old infant recently had a seizure and is lethargic and bradycardic upon arriving at the emergency room. The clinical exam revealed a retinal hemorrhage. The nurse suspects that the child is showing signs and symptoms of:
shaken baby syndrome
A child is admitted to the pediactric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST?
place in respiratory isoloation
A client at 34 weeks gestation is receiving terbutaline (Brethine) subcutaneously. Her contractions increase to every 5 minutes, and her cervix dilates to 4 cm, the tocolytic is discontinued. What is the priority nursing care during this time?
promoting maternal-fetal well-being during labor
A nurse is preparing a plan of care for a pregnant client who will be given oxytocin to induce labor. Which occurrence does the nurse include in the plan of care as a reason for immediate discontinuation of the oxytocin infusion?
uterine hyperstimulation
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?
Raise the foot of the bed