SOC Exam 1 - Saunders NCLEX Review Book

A client in labor is transported to the delivery room and prepared for a c-section. After the client is transferred to the delivery table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with legs in stirrups 3. Prone position with legs separated and elevated 4. Semi-Fowler's position with a pillow under knees

1

A mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which? 1. A wagon 2. A golf set 3. A farm set 4. A jack set with marbles

1

An infant of a mother infected with HIV is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign? 1. Cough 2. Liver fatigue 3. Watery stool 4. Nuchal rigidity

1

Sulfisoxazole, 1g orally twice daily is prescribed for an adolescent with a UTI. The medication label reads "500 mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent? 1. 1/2 tablet 2. 1 tablet 3. 2 tablets 4. 3 tablets

3

The nurse is assessing a client in the fourth stage of labor and notes the fundus is firm, but the bleeding is excessive. Which should bee the initial nursing action? 1. Record the findings 2. Massage the fundus 3. Notify HCP 4. Place client in Trendelenburg

3

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment to the monitor, what is the next nursing action? 1. Identify the types of accelerations 2. Assess baseline FHR 3. Determine intensity of contractions 4. Determine frequency of contractions

2

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door" 2. "Some health care personnel won't have name badges" 3. "I will ask the nurse to attend to my infant if my husband is not here and I am napping" 4. "It's okay to allow the nurse assistant to carry my newborn to the nursery"

3

The nurse is assisting a client undergoing induction at 41 weeks. The client's contractions are moderate and occurring every 2 - 3 minutes with a duration of 60 seconds. An internal FHR monitor is in place. The baseline FHR has been 120-122 bpm for the past hour. What is the priority nursing action? 1. Notify HCP 2. Discontinue infusion of oxytocin 3. Place O2 on at 8-10 L/min via face mask 4. Contact client's primary support persons if not currently present

2

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4 F (38 C) 2. A increase in pulse rate from 88 to 102 bpm 3. A BP change from 130/88 to 124/80 mmHg 4. An increase in the respiratory rate from 18 to 22 BPM

2

The nurse is performing an assessment of a client who is scheduled for a c-section at 39 weeks. Which assessment finding indicates the need to call the HCP? 1. Hgb of 11 g/dL (110 mmol/L) 2. Fetal heart rate of 180 bpm 3. Maternal pulse of 85 bpm 4. WBC count of 12,000 mm3

2

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1. Elevate the client's legs 2. Massage the fundus until it is firm 3. Ask the client to turn on her left side 4. Push on the uterus to assist in expressing clots

2

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure 2. Reinforce the dressing 3. Document the findings 4. Contact HCP

3

The nurse is assisting the HCP examining a 3 week old infant for developmental dysplasia of the hip. What test or sign should the nurse expect the HCP to assess? 1. Babinski's sign 2. The Moro Reflex 3. Ortolani's maneuver 4. The palmar-plantar grasp

3

The nurse is performing an assessment of a pregnant client who is 28 weeks of gestation. The nurse measures the fundal height in cm, and notes it is approximately 30 cm. How should the nurse interpret this finding? 1. The client is measuring large for gestational age 2. The client is measuring small for gestational age 3. The client is measuring normal for gestational age 4. More evidence is needed to determine size for gestational age

3

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clot and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document findings 2. Reassess client in 2 hours 3. Notify HCP 4. Encourage increased oral intake of fluids

3

Which assessment following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. FHR pattern 4. Maternal BP

3

The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? 1. "We need to encourage our child to drink fluids." 2. "Coughing spells may be triggered by dust or smoke." 3. "Vomiting may occur when our child has coughing episodes." 4. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."

4

The postpartum nurse is taking the vitals of client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 F. What is the priority nursing action? 1. Document the findings 2. Retake the temperature in 15 mintues 3. Notify HCP 4. Increase hydration by encouraging oral fluids

4

The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant."

1

The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent? 1. The hepatitis B vaccine will not be given to the child. 2. The inactivated influenza vaccine will be given yearly. 3. The varicella vaccine will be given before 6 months of age. 4. A Western blot test needs to be performed and the results evaluated before immunizations.

2

The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should plan care with the understanding that which childhood psychosocial need occurs at this age? 1. "Being sick is scary" 2. "I know it hurts to die" 3. "I know I will be healthy soon" 4. "I know I am different than other kids"

2

The nurse is planning care for a newborn of a mother with diabetes. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen

2

The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. Subcutaneous 4. Intramuscular

2

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of birth 4. Within 2 weeks postpartum

1

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord she noticed the cord was moist and that discharge was present. What is the most appropriate nursing action for this mother? 1. Bring the infant to the clinic 2. This is a normal occurrence and no further action is needed 3. Increase the number of times the cord is cleaned per day 4. Monitor cord for another 24 - 48 hours and call the clinic if the discharge continues

1

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. 1. Cyanosis 2. Tachypnea 3. Hypotension 4. Retractions 5. Audible grunts 6. Barrel chest

1, 2, 4, 5

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of the finding, which nursing action is appropriate? 1. Contact HCP 2. Instruct client to maintain bed rest for the remainder of the pregnancy 3. Inform the client that these contractions are common and may occur throughout the pregnancy 4. Call the maternity unit and inform them that the client will be admitted in a preterm labor condition

3

The nurse administers erythromycin ointment (0.5%) to a newborn's eyes and the mother asks why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized 2. Prevents cataracts in the newborn born in a woman who is susceptible to rubella 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor 4. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with untreated gonnococcal infection

4

The nurse is creating a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow newborn to establish own sleep-rest pattern 2. Maintain the newborn in brightly lit area of nursery 3. Encourage frequent handling of newborn by parents and staff 4. Monitor the newborn's response to feedings and weight gain pattern

4

The nurse prepares to administer phytonadione (vitamin K) injection to a newborn and the mother asks why the infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs the medicine to develop immunity" 2. "The medicine will protect your newborn from being jaundiced" 3. Newborns have sterile bowels and the medicine promotes the growth of bacteria in the bowel" 4. "Newborns are deficient in Vitamin K, and this injection prevents your newborn from bleeding"

4

The nurse is reviewing the record of a client in the labor room and notes the HCP has documented the fetal presenting part at -1 station. What does this mean in relation to the ischial spine? **question in book uses a figure, but I had to make it a ?**

1 cm above ischial spine

The nurse is preparing a list of self care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra 2. Rest during the active phase 3. Maintain a fluid intake of at least 3000 mL/day 4. Continue to breastfeed if the breasts are not sore 5. Take the prescribed antibiotics until the soreness subsides 6. Avoid decompression of the breasts by breastfeeding or breast pump

1, 2, 3, 4

Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Monitor the child's weight. 2. Frequent hand-washing is important. 3. The child should avoid exposure to other illnesses. 4. The child's immunization schedule will need revision. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.

1, 2, 3, 5

The nurse is providing postpartum instructions for a client who will be breast feeding her newborn. The nurse determines that the client understands the instructions if she makes which statement? Select all that apply. 1. "I should wear a bra that provides support" 2. "Drinking alcohol can affect my milk supply" 3. "The use of caffeine can decrease my milk supply" 4. "I will start my estrogen birth control pills again as soon as I get home" 5. "I know if my breasts get engorged, I will limit my BF and supplement the baby" 5. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily"

1, 2, 3, 6

A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instruction(s) should the nurse provide to the parent? Select all that apply. 1. Set limits on the child's behavior 2. Ignore the child when this behavior occurs 3. Allow the behavior, because this is normal at this age period 4. Provide a simple explanation of why the behavior is unacceptable 5. Punish the child every time the child says "no" to change this behavior

1, 4

Which interventions are appropriate for the care of an infant? SELECT ALL THAT APPLY 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at nap time. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

1, 4, 5

The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? 1. Increase oral fluids. 2. Document the finding. 3. Notify the health care provider (HCP). 4. Elevate the head of the bed to 90 degrees.

2

A 4-year-old child sustains a fall at home and after an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? 1. "The cast may feel warm as the cast dries." 2. "I can use lotion or powder around the cast edges to relieve itching." 3. "A small amount of white shoe polish can touch up a soiled white cast." 4. "If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."

2

A client in preterm labor at 31 weeks is dilated 4 cm. She has been started on Mg sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine 2. Betamethasone 3. Rh 0 (D) immune globulin 4. Dinoprostone vaginal insert

2

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring Hcg and Hct levels

2

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately" 2. "The vaginal discharge may be bothersome, but is a normal occurrence." 3. "Report to the ED at the maternity center immediately" 4. "Use tampons if the discharge is bothersome, but be sure to change them every 2 hours"

2

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1. Encourage the mother to BF soon after birth 2. Support the mother in her reaction to the newborn infant 3. Tell the mother that it is important to hold the newborn infant 4. Document a complete account of the mother's reaction on the birth record

2

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration, what is the priority assessment? 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes

2

The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother? 1. Allow the bottle if it contains juice. 2. Allow the bottle if it contains water. 3. Do not allow the child to have the bottle. 4. Allow the bottle during naps but not at bedtime.

2

A rubella titer result of a 1 day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breastfeeding (BF) needs to be stopped for 3 months 2. Pregnancy needs to be avoided for 1 - 3 months 3. The vaccine is administered by the subcutaneous route 4. Exposure to immunosuppressed individuals needs to be avoided 5. A hypersensitivity reaction can occur if the client has an allergy to eggs 6. The area of the injection needs to be covered with a sterile gauze for 1 week

2, 3, 4, 5

The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply. 1. Individuals move through all six stages in a sequential fashion 2. Moral development progresses in relationship to cognitive development 3. A person's ability to make moral judgements develops over a period of time 4. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior 5. In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society 6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned

2, 3, 4, 6

A pregnant client is receiving Mg sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. 1. Proteinuria of 3+ 2. Respirations of 10 BPM 3. Presence of deep tendon reflexes 4. Urine output of 20 mL per hour 5. Serum Mg level of 4 mEq/L

2, 4

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? 1. "Treatment needs to be started as soon as possible." 2. "I realize my infant will require follow-up care until fully grown." 3. "I need to bring my infant back to the clinic in 1 month for a new cast." 4. "I need to come to the clinic every week with my infant for the casting."

3

The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial developmental theory, the nurse should make which response? 1. "You need to be concerned" 2. "You need to monitor the child's behavior closely" 3. "At this age, the child is developing his own personality" 4. "You need to provide more praise to the child to stop this behavior"

3

The nurse is assessing a client who is 6 hours postpartum after delivering a full term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? 1. Raise the head of the client's bed 2. Obtain Hgb and Hct levels 3. Instruct the client to request help when getting out of bed 4. Inform nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided

3

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vitals 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of tearing sensation

1

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probably signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. 1. Ballotment 2. Chadwick's sign 3. Uterine enlargement 4. Positive pregnancy test 5. Fetal heart rate detected by nonelectronic device 6. Outline of fetus via radiography or ultrasonography

1, 2, 3, 4

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nagele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12, 2019 2. July 26, 2019 3. August 12, 2019 4, August 26, 2019

2

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate? 1. Administer oxygen. 2. Document the findings. 3. Notify the health care provider. 4. Reassess the respiratory rate in 15 minutes.

2

The nurse creates a plan of care for a woman with HIV infection and her newborn. The nurse should include what intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the infant 3. Initiating referral to evaluate for blindness, learning problems, or behavioral problems 4. Instructing the BF mother regarding treatment of the nipples with nystatin ointment

2

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

2

The nurse in a NICU receives a phone call to prepare for the administration of a 43 week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. Turn on the apnea and cardiorespiratory monitors 2. Connect the resuscitation bag to the oxygen outlet 3. Set up the IV line with 5% dextrose in water 4. Set the radiant warmer control temperature at 36.5C or 97.6F

2

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts". Which statement by the client indicates need for further instruction? 1. "I will record the # of movements or kicks" 2. "I need to lie flat on my back to perform this procedure" 3. "If I count fewer than 10 kicks in a 2 hour period I should count the kicks again over the next 2 hours" 4. "I should place my hands on the largest part of my abdomen and concentrate of the fetal movements to count the kicks"

2

The 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 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

2

The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child? 1. Uses a fork to eat 2. Uses a cup to drink 3. Pours own milk into a cup 4. Uses a knife for cutting food

2

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight 6 lb, 14 oz (3120 g) 4. Head circumference appropriate for gestational age

2

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast fed. The nurse should provide which instruction to the mother? 1. Feed the newborn less frequently 2. Continue to BF every 2 - 4 hours 3. Switch infant to bottle feeding for 2 weeks 4. Stop BF and switch to bottle feeding permanently.

2

A 6-year-old child with human immunodeficiency virus (HIV) has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child? 1. "The pain will go away if you lie still and let the medicine work." 2. "Try not to think about it. The more you think it hurts, the more it will hurt." 3. "I know it must hurt, but if you tell me when it does, I will try and make it hurt a little less." 4. "Every time it hurts, press on the call button and I will give you something to make the pain go all away."

3

A pediatric client with ventricular septal defect repair is placed on a maintenance dose of digoxin. The dosage is 8 mcg/kg/day and the client weighs 7.2 kg. The HCP prescribes digoxin to be given twice daily. The nurse prepares how many mcg of digoxin to administer to the client at each dose? 1. 12.6 mcg 2. 21.4 mcg 3. 28.8 mcg 4. 32.2 mcg

3

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should be taking which initial action? 1. Document the findings 2. Elevate the client's legs 3. Massage the fundus until it is firm 4. Push on the uterus to assist in expressing clots

3

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the rooms 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3

The nurse is preparing to care for four assigned clients. Which client is most at risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A primiparous client who delivered 6 hours ago 3. A multiparous client who delivered a large baby after oxytocin induction 4. A primiparous client who delivered 6 hours ago and had epidural anesthesia

3

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. Strict bed rest required after procedure 2. Hospitalization necessary for 24 hours after procedure 3. Informed consent needs to be signed before procedure 4. A fever is expected after procedure because of the trauma to the abdomen

3

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? 1. "I will encourage my child to perform prescribed exercises." 2. "I will have my child wear soft fabric clothing under the brace." 3. "I should apply lotion under the brace to prevent skin breakdown." 4. "I should avoid the use of powder because it will cake under the brace."

3

The nurse is providing medication instructions to a parent. Which statement by the parent indicates need for further instruction? 1. "I should cuddle with my child after giving the medication" 2. "I can give my child a frozen juice bar after he swallows the medication" 3. "I should mix the medication in the baby food and give it when I feed my child" 4. "If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw"

3

The postpartum nurse is assessing a client who delivered a healthy infant by c-section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply. 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Late deceleration of FHR 5. Early deceleration of FHR

3, 4

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of the newborn? Select all that apply. 1. Lethargy 2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort 6. Cuddles when being held

3, 4, 5

A client arrives at the birthing center in active labor. Following examination it is determined that her membranes are still intact and she is at -2 station. The HCP prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of this procedure? Select all that apply. 1. Less pressure on her cervix 2. Decreased # of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring 5. The need for frequent FHR monitoring to detect presence of prolapsed cord

3, 5

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. Contractions are regular 2. Membranes have ruptured 3. Cervix is completely dilated 4. Client begins to expel clear vaginal fluid 5. Spontaneous urge to push is initiated from perineal pressure

3, 5

A HCP's prescription reads "ampicillin sodium 125mg IV every 6 hours." The medication label reads "when reconstituted with 7.4 mL of bacteriostatic water, the final concentration is 1g/7.4 mL." The nurse prepares to draw up how many mL to administer one dose? 1. 1.1 mL 2. 0.54 mL 3. 7.425 mL 4. 0.925 mL

4

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? 1. Administer an analgesic 2. Release the skin traction 3. Apply ice to the extremity 4. Notify the HCP

4

A child is placed in skeletal traction for treatment of a fractured femur. The nurse develops a plan of care and includes which intervention? 1. Ensure that all ropes are outside the pulleys. 2. Ensure that the weights are resting lightly on the floor. 3. Restrict diversional and play activities until the child is out of traction. 4. Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied

4

A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance? 1. Eggs 2. Penicillin 3. Sulfonamides 4. A previous dose of hepatitis B vaccine or component

4

A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant? 1. Chest x-ray 2. Western blot 3. CD4+ cell count 4. p24 antigen assay

4

Rh 0 (D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that if will protect her next baby from which condition? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiologic jaundice 4. Being affected by Rh incompatibility

4

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the pre-conventional level? 1. Peer pressure 2. Social pressure 3. Parent's behavior 4. Punishment and reward

4

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

4

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation 2. Decreased fluid intake 3. Expose all of the newborn's skin 4. Monitor skin temperature closely 5. Reposition newborn every 2 hours 6. Cover the newborn's eyes with eye shields or patches

4, 5, 6

The 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? 1. "We will be sure not to leave hot liquids unattended." 2. "I guess my children need to understand what the word hot means." 3. "We will be sure that the children stay in their rooms when we work in the kitchen." 4. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen."

1

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition? 1. Limited range of motion in the affected hip 2. An apparent lengthened femur on the affected side 3. Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed 4. Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table

1

A 4 year old child is diagnosed with leukemia and is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child 2. Encourage play with other children of the same age 3. Advise the family to visit only during the scheduled visiting hours 4. Provide a private room, allowing the child to bring favorite toys from home

1

A nonstress test is performed on a pregnant client and the results indicate nonreactive findings. The HCP prescribes a contraction stress test and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a c-section

1

The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? 1. Allow the newborn infant to signal a need 2. Anticipate all the needs of the newborn infant 3. Attend to the newborn infant immediately when crying 4. Avoid the newborn infant during the first 10 minutes of crying

1

The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed? 1. "I will flush the eyes after instilling the ointment" 2. "I will clean the newborn's eyes before instilling ointment" 3. "I need to administer the eye ointment within 1 our of delivery" 4. "I will instill the eye ointment into each of the newborn's conjunctival sacs"

1

The nurse has provided discharge instructions to a client who delivered a healthy newborn by c-section. Which statement by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately" 2. "I will notify the HCP if I develop a fever" 3. "I will turn on my side and push with my arms to get out of bed" 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks"

1

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen by face mask 2. Place mother in supine position 3. Increase the rate of the oxytocin IV infusion 4. Document the findings and continue to monitor the fetal patterns

1

The nurse is describing Piaget's cognitive developmental theory to the pediatric nursing staff. The nurse should tell the staff that which child behavior is characteristic of the formal operations stage? 1. The child has the ability to think abstractly 2. The child begins to understand the environment 3. The child is able to classify, order, and sort facts 4. The child learns to think in terms of past, present, and future

1

The nurse is monitoring a client in active labor and notes the client is having contractions every 3 minutes that last 45 seconds. The nurse notes the FHR between contractions is 100 bpm. Which nursing action is most appropriate? 1. Notify HCP 2. Continue monitoring FHR 3. Encourage client to continue pushing with each contraction 4. Instruct client's coach to continue to encourage breathing techniques

1

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1

The nurse is teaching a postpartum client about breastfeeding. Which instruction should the nurse include? 1. The diet should include additional fluids 2. Prenatal vitamins should be discontinued 3. Soap should be used to cleanse the breasts 4. Birth control measures are unnecessary while BF

1

The nurse notes that a 6 year child does not recognize that objects exist even when the objects are outside the visual field. Based on this observations, which action should the nurse take? 1. Report the observation to the health care provider 2. Move the objects in the child's direct field of vision 3. Teach the child how to visually scan the environment 4. Provide additional lighting for the child during play activities

1

The nursing instructor asks a nursing student to present a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student plans the conference, knowing that which characteristic relates to this stage of development? 1. This stage is associated with toilet training 2. This stage is characterized by the gratification of self 3. This stage is characterized by a tapering off of conscious biological and sexual urges 4. This stage is associated with pleasurable and conflicting feelings about the genital organs

1

Which car safety device should be used for a child who is 8 years old and is 4 feet tall? 1. Seat belt 2. Booster seat 3. Rear-facing convertible seat 4. Front-facing convertible seat

2

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold. 2. The child had a previous anaphylactic reaction to the vaccine. 3. Mother reports that the child is having intermittent episodes of diarrhea. 4. Mother reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. Mother reports that the child has recently been exposed to an infectious disease.

2, 5

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. 1. Use the fingertips to lift the cast while it is drying. 2. Keep small toys and sharp objects away from the cast. 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. 5. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6. Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity

2, 5, 6

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform ROM exercises at this time. The nurse should make which response? 1. "Avoid all exercise during painful periods" 2. "ROM exercises must be performed everyday" 3. "Have the child perform simple isometric exercises during this time" 4. "Administer additional pain medication before performing ROM exercises"

3

The nurse is preparing care for a dying client and several family members are at the bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing 2. Make the decisions for the family 3. Encourage expression of feelings, concerns, and fears 4. Explain everything that is happening to all family members 5. Touch and hold the client's or family member's hand if appropriate 6. Be honest and let the client and family know the will not be abandon by the nurse

3, 5, 6

A 16-year-old is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the child to rest and read. 2. Encourage the parents to room in with the child. 3. Allow the family to bring in the child's favorite computer games. 4. Allow the child to interact with others in his or her same age group.

4

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action? 1. Administer an antiemetic. 2. Increase the intravenous fluids. 3. Place the child in a Sims's position. 4. Notify the health care provider (HCP).

4

A client in postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardia and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Start an IV line 2. Assess the client's BP 3. Prepare to administer morphine sulfate 4. Administer oxygen 8-10 L/minute by face mask

4

A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother? 1. Allow the child to set bedtime limits. 2. Allow the child to have temper tantrums. 3. Avoid letting the child nap during the day. 4. Inform the child of bedtime a few minutes before it is time for bed.

4

A parent brings her 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? 1. Varicella, hepatitis B vaccine (HepB) 2. Diphtheria, tetanus, acellular pertussis (DTaP); measles, mumps, rubella (MMR); inactivated poliovirus vaccine (IPV) 3. MMR, Haemophilus influenzae type b (Hib), DTaP 4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus (RV)

4

An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply a hot pack to the injection site. 4. Apply a cold pack to the injection site.

4

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the health care provider who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease

4

Penicillin G procaine 1,000,000 units IM is prescribed for a child with an infection. The medication label reads "1,200,000 units per 2 mL." The nurse has determined that the dose prescribed is safe. The nurse administers how many mL per dose to the child? 1. 0.8 mL 2. 1.2 mL 3. 1.4 mL 4. 1.7 mL

4

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. The nurse should make which most appropriate response to the mother? 1. "I am so pleased also that everything has turned out fine." 2. "Because symptoms have not developed, it is unlikely that your infant will develop HIV infection." 3. "Everything looks great, but be sure that you return with your infant next month for the scheduled visit." 4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

4

The nurse is caring for a client in labor and is monitoring FHR patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify HCP 2. Reposition mother and check monitor for changes in FHR 3. Take mother's vitals, tell mother that bed rest is required to conserve O2 4. Document the findings, tell mother the pattern on the monitor indicates fetal well being

4

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? 1. The client with mild afterpains 2. The client with a pulse rate of 60 bpm 3. The client with colostrum discharge form both breasts 4. The client with lochia that is red and has a foul smelling odor

4

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Encourage hourly ambulation 2. Assess vitals every 4 hours 3. Measure fundal height every 4 hours 4. Prepare an icepack for application to the area

4

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? 1. Document the finding 2. Encourage the client to ambulate 3. Encourage the client to increase fluid intae 4. Contact HCP and inform of the finding

4

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? 1. A radio 2. A sports video 3. Large picture books 4. Crayons and a coloring book

4

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breastfeeding her newborn. Which statement would indicate the need for further instruction? 1. "I should breastfeed every 2-3 hours" 2. "I should change the breast pads frequently" 3. "I should wash my hands well before BF" 4. "I should wash my nipples daily with soap and water"

4

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops" 2. "My contractions will be felt in my abdominal area" 3. "My contractions will not be as painful if I walk around" 4. "My contractions will increase in duration and intensity"

4

The nurse prepares to administer an IM injection to a 4 month old infant. The nurse selects which best site to administer the injection? 1. Ventrogluteal 2. Lateral deltoid 3. Rectus femoris 4. Vastus lateralis

4

The nurse provides home care instructions to the parent of a child with AIDS. Which statement by the parent indicated need for further teaching? 1. "I will wash my hands frequently" 2. "I will keep my child's immunizations up to date" 3. "I will avoid direct unprotected contact with my child's bodily fluids" 4. "I can send my child to day care if he has a fever as long as it is a low grade fever"

4