Compass Module 1
An older female client asks a nurse why her hair has turned gray. Which response is most appropriate for the nurse to make to the client? "The number of sweat glands and blood vessels decreases in the normal aging process." "A loss of melanin occurs in the normal aging process." "The skin on the scalp becomes thin, causing moisture to escape." "It is caused by hereditary factors."
"A loss of melanin occurs in the normal aging process."
A nurse provides information to a client about the use of a diaphragm. Which statement indicates to the nurse that the client needs further information on how to use the diaphragm? "The diaphragm can be inserted as long as 6 hours before intercourse." "I can leave the diaphragm in place as long as I want after intercourse." "I need to reapply spermicidal cream with repeated intercourse." "The diaphragm needs to be filled with spermicidal cream before insertion."
"I can leave the diaphragm in place as long as I want after intercourse."
The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information? "I should eat five or six small meals a day rather than three full meals." "I need to be sure to drink adequate fluids with my meals." "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning." "I need to avoid eating fried or greasy foods."
"I need to be sure to drink adequate fluids with my meals."
A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? "I need to wear additional antiperspirant and deodorant in warm weather." "I need to wear a hat with a wide brim when I go outdoors." "I should drink extra fluids during the summer." "I should wear cool, light clothing in warm weather."
"I need to wear additional antiperspirant and deodorant in warm weather."
A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? "The drop side needs to be impossible for my infant to release." "I need to keep large toys out of the crib." "The distance between the slats needs to be no more than 4 inches (10 cm) wide to prevent entrapment of my infant's head or body." "Wood surfaces on the crib need to be free of splinters and cracks."
"The distance between the slats needs to be no more than 4 inches (10 cm) wide to prevent entrapment of my infant's head or body."
A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? "Yes, your infant is protected from all infections." "The transfer of your antibodies protects your infant until the infant is 12 months old." "If you breastfeed, your infant is protected from infection." "The immune system of an infant is immature, and the infant is at risk for infection."
"The immune system of an infant is immature, and the infant is at risk for infection."
A nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take? Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse. Asks the mother to lie still while both the FHR and the radial pulse rate are counted.
Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.
A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. What should the nurse tell the client? Devices that apply pressure alone are available over the counter Complementary alternative therapies should not be used during pregnancy The primary health care provider or nurse-midwife needs to provide a prescription for acupressure It is all right to try any type of complementary alternative therapy to relieve the nausea
Devices that apply pressure alone are available over the counter
A nurse is reviewing the medical record of an older client with presbycusis. Which findings should the nurse expect to note in the client's record? Select all that apply. Improved hearing ability during conversational speech Difficulty hearing low-pitched tones Unilateral conductive hearing loss Difficulty hearing consonants during conversational speech Gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve Difficulty hearing whispered words in the voice test
Difficulty hearing consonants during conversational speech Gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve Difficulty hearing whispered words in the voice test
A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. Which action should the nurse take? Wait 15 minutes and then recheck the FHR Notify the primary health care provider of the finding Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time Document the findings
Document the findings
A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per minute. Based on this finding, what is the most appropriate action for the nurse to take? Place the infant in an oxygen tent Wrap an extra blanket around the infant Document the findings Contact the pediatrician
Document the findings
A nurse performing a neurological assessment of a client in later adulthood notes that the client has tremors of the hands. Based on this finding, which action should the nurse take? Document the findings Notify the primary health care provider immediately Obtain a prescription for a muscle relaxant Ask the primary health care provider about referring the client to a neurological specialist
Document the findings
A nurse is obtaining assessment data from an older client about sleep patterns. The client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on the data, which action should the nurse take? Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours Report the findings to the primary health care provider Ask the primary health care provider for a prescription for a nighttime sedative Document the findings in the medical record
Document the findings in the medical record
A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding? Check the client's temperature. Obtain a sample of the amniotic fluid for laboratory analysis. Report the findings to the nurse-midwife. Document the findings.
Document the findings.
A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? Suggest to the pediatrician that a skull x-ray be performed Tell the mother that the infant is growing faster than expected Document these measurements in the infant's health-care record Suspect the presence of hydrocephalus
Document these measurements in the infant's health-care record
A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. Based on this finding, which action by the nurse is most appropriate? Documenting the finding Reporting the finding to the nurse-midwife or primary health care provider immediately Performing active and passive range-of-motion exercises Helping the woman get out of bed and walk
Documenting the finding
A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? Stethoscope Fetoscope Pulse oximetry on the client and a fetoscope Doppler transducer
Doppler transducer
A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action? Gently stimulate the infant by rubbing his back while administering oxygen Recheck the score in 5 minutes Provide no action except to support the infant's spontaneous efforts Initiate cardiopulmonary resuscitation
Gently stimulate the infant by rubbing his back while administering oxygen
The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. What should the nurse instruct the mother to do? Schedule an appointment with a dentist for a dental evaluation Obtain an over-the-counter (OTC) topical medication for gum-pain relief Rub the infant's gums with baby aspirin that has been dissolved in water Give the infant cool liquids or a Popsicle and hard foods such as dry toast
Give the infant cool liquids or a Popsicle and hard foods such as dry toast
According to Erik Erikson's developmental theory, which is a developmental task of the middle adult? Making decisions concerning career, marriage, and parenthood Verbalizing readiness to assume parental responsibilities Guiding social interactions with the next generation Providing guidance during interactions with children Redefining self-perception and capacity for intimacy Willingness to care for others
Guiding social interactions with the next generation Providing guidance during interactions with children Willingness to care for others
A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, which action should the nurse take? Allow the toddler to play with other children in the nursing unit playroom Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room Keep hospital routines as similar as possible to those at home Spend as much time as possible with the toddler
Keep hospital routines as similar as possible to those at home
A nurse is performing a skin and peripheral vascular assessment on a client in later adulthood. Which observation should the nurse expect to note as an age-related finding? Thick skin on the lower legs Bounding dorsalis pedis pulse Thin, ridged toenails Loss of hair on the lower legs
Loss of hair on the lower legs
A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which task represents the primary developmental task of this child? Engaging in tasks they can complete Developing a sense of trust in the world Developing a sense of control over self and body functions Mastering useful skills and tools Developing a sense of accomplishment Gaining independence from parents
Mastering useful skills and tools Developing a sense of accomplishment Engaging in tasks they can complete
After delivery, the nurse assesses the woman's uterine fundus. At what locations does the nurse expect to be able to palpate the fundus during the first 24 hours? Select all that apply. In the pelvic cavity Midway between the symphysis pubis and umbilicus Rises to a level just above the umbilicus 2 cm above the umbilicus Sinks to the level of the umbilicus At the level of the umbilicus
Midway between the symphysis pubis and umbilicus Rises to a level just above the umbilicus Sinks to the level of the umbilicus
A nurse is planning dietary measures for an older client who is experiencing dysphagia. Which action should the nurse include in the plan of care? Ensuring that most of the diet consists of liquids Encouraging the client to feed herself Consulting with the health care provider regarding feeding through an enteral tube Monitoring the client during meals to ensure that food is swallowed
Monitoring the client during meals to ensure that food is swallowed
Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication. What should the nurse tell the couple? The primary health care provider should be notified immediately if breast engorgement occurs If the oral tablets are not successful, the medication will be administered intravenously The couple should engage in coitus once a week during treatment Multiple births occur in a small percentage of clomiphene-facilitated pregnancies
Multiple births occur in a small percentage of clomiphene-facilitated pregnancies
A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F (38.1°C), the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. Based on these findings, what is the most appropriate nursing action? Document the findings in the client's medical record Continue collecting subjective and objective data Notify the nurse-midwife of the findings Recheck the vital signs in 1 hour
Notify the nurse-midwife of the findings
A prescription is written to administer hepatitis B vaccine to a newborn infant. Before administering the vaccine, which action should the nurse take? Obtain parental consent to administer the vaccine Check the infant for jaundice Check the infant's temperature Request that a hepatitis blood screen be performed on the infant
Obtain parental consent to administer the vaccine
A nurse observes an assistive personnel (AP) communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the AP performs which action? Uses facial expressions or gestures Speaks at a normal rate and volume Uses short sentences Overarticulates words
Overarticulates words
A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. Which question should the nurse ask to identify risk factors associated with the use of an oral contraceptive? "Do you smoke cigarettes?" "Are you dieting?" "Do you engage in strenuous exercise such as jogging?" "Do you normally have menstrual cramps with your periods?"
"Do you smoke cigarettes?"
A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? "Fluoride supplementation is not necessary until permanent teeth come in." "I can mix the food in my infant's bottle if he won't eat the food." "Egg white should not be given to my infant because of the risk for an allergy." "Meats are really important for iron, and I should start feeding meats to my infant right away."
"Egg white should not be given to my infant because of the risk for an allergy."
A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client? "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth." "A 2-year-old toddler will be more concerned about exploring the environment, so there's no reason to be concerned." "If your 2-year-old becomes angry or jealous, you should have the child seen by a child psychologist." "Don't be concerned; any 2-year-old would welcome a newborn."
"Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth."
A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her primary health care provider. Which statement by the mother indicates a need for further information? "Feelings of pelvic fullness or pelvic pressure are a sign of a problem." "My temperature needs to remain within a normal range." "I will call my nurse-midwife if I get any redness, swelling, or tenderness in my legs." "Frequent urination and burning when I urinate are expected."
"Frequent urination and burning when I urinate are expected."
A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed? 8 weeks 16 weeks 6 weeks 12 weeks
16 weeks
A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, which should the nurse ensure? The woman's husband remains in the examining room at all times A female primary health care provider examines the woman Written permission is obtained from the woman to obtain subjective health data The woman is examined without any other people in the examining room
A female primary health care provider examines the woman
A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. How should the nurse interpret this finding? A nonreassuring sign A reassuring sign An indication of the need to contact the primary health care provider An indication of fetal distress
A reassuring sign
A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse should select an activity that will assist in developing which psychosocial stage? Autonomy A sense of trust A sense of industry Initiative
A sense of industry
A nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which finding is noted on the electronic monitoring recording strip? Acceleration of the FHR by 25 to 30 beats per minute for at least 15 seconds in response to fetal movement Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats per minute for 15 seconds Two fetal heart accelerations within a 20-minute period, peaking at 15 beats per minute above baseline and lasting 15 seconds from baseline to baseline Absence of accelerations after fetal movement
Absence of accelerations after fetal movement
A nurse is assessing the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform? Select all that apply. Align two or more blocks Put on and tie his shoes Go to the bathroom without help Turn the pages of a book one at a time Dress himself appropriately Washing and drying hands
Align two or more blocks Turn the pages of a book one at a time Washing and drying hands
A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members should the nurse ask the client? Spouse's children from a previous marriage Foster children and their parents Spouse and spouse's parents Aunts, uncles, grandparents, and cousins
Aunts, uncles, grandparents, and cousins
A nurse is assessing a newborn infant for jaundice. Which action should the nurse take to assess the infant for its presence? Apply pressure with a finger over the umbilical area Squeeze the infant's nail beds Apply pressure with a finger on the infant's forehead Squeeze the infant's brachial area
Apply pressure with a finger on the infant's forehead
A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is most appropriate? Administering an intravenous (IV) opioid analgesic Assisting the woman in taking a warm sitz bath Applying an ice pack to the perineum Contacting the nurse-midwife or primary health care provider
Applying an ice pack to the perineum
A nurse is performing an admission assessment on an older client who will be seen by a primary health care provider in a health care clinic. When the nurse asks the client about sexual and reproductive function, he reports concern about sexual dysfunction. What is the next action the nurse should take? Document the client's concern in the medical record. Ask the client about medications he is taking. Tell the client that sexual dysfunction is a normal age-related change. Report the client's concern to the primary health care provider.
Ask the client about medications he is taking.
A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. Where should the nurse place the tape measure? At the level of the umbilicus 2 inches (5cm) below the nipples At the level of the nipples In the axillary area
At the level of the nipples
A nurse is reviewing the medical notes of a client seen by the primary health care provider to determine whether the client is pregnant. What positive signs/symptoms of pregnancy would the nurse expect to see in the client's medical notes? Select all that apply. Thinning of the cervix Amenorrhea Auscultation of fetal heart sounds Palpable fetal movement Visualization of the fetus with sonography Positive result on home urine test for pregnancy
Auscultation of fetal heart sounds Palpable fetal movement Visualization of the fetus with sonography
The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? Industry versus inferiority Initiative versus guilt Trust versus mistrust Autonomy versus doubt and shame
Autonomy versus doubt and shame
The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. What should the nurse tell the mother? Hepatitis B is a concern with body piercing Body piercing is generally harmless as long as it is performed under sterile conditions Infection always occurs when body piercing is done It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV)
Body piercing is generally harmless as long as it is performed under sterile conditions
A nurse monitoring a client in labor notes this fetal heart rate pattern (refer to figure) on the electronic fetal monitoring strip. Which is the most appropriate nursing action? Continue to monitor the client and fetal heart rate patterns Stop the oxytocin (Pitocin) infusion Notify the nurse-midwife or primary health care provider Administer oxygen with a face mask at 8 to 10 L/min
Continue to monitor the client and fetal heart rate patterns
A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which area? Back of the fetus Brachial area of one extremity of the fetus Chest of the fetus Carotid artery in the neck of the fetus
Back of the fetus
A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which toy is most appropriate for these activities? Simple board games and puzzles Blocks and push-pull toys Videos and cutting-and-pasting toys Finger paints and card games
Blocks and push-pull toys
A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push? Blowing repeatedly in short puffs Holding her breath and using the Valsalva maneuver Deep inspiration and expiration at the beginning and end, respectively, of each contraction Cleansing breaths
Blowing repeatedly in short puffs
A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse plans care knowing that the most likely primary concern of the teenager is which? Keeping up with schoolwork Obtaining adequate rest and sleep Obtaining adequate nutrition Body image
Body image
A school nurse provides information to the parents of school-age children regarding appropriate dental care. What should the nurse tell the parents their children should do? Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime Brush and floss their teeth every morning and at bedtime Brush their teeth every morning and at bedtime Brush and floss their teeth after meals and at bedtime
Brush and floss their teeth after meals and at bedtime
A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats per minute. Based on this finding, which priority action should the nurse take? Documenting the vital signs in the client's medical record Notifying the nurse-midwife immediately Continuing to check the client's vital signs every 15 minutes Checking the client's uterine fundus
Checking the client's uterine fundus
A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL (2.2 mmol/L). Based on this result, which action should the nurse take first? Document the results in the newborn's medical record Contact the nurse-midwife or primary health care provider Ask the laboratory to draw another blood sample in 2 hours and repeat the test Hold the next scheduled feeding
Contact the nurse-midwife or primary health care provider
An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is which? Checking the amniotic fluid for intrauterine infection Determination of fetal lung maturity Checking the fetal cells for chromosomal abnormalities Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid
Determination of fetal lung maturity
A nurse provides information to a pregnant client with hemorrhoids about measures that will alleviate her discomfort. Which actions does the nurse tell the client to take? Select all that apply. Shower daily but avoid sitting in a bathtub Elevate her hips on a pillow when resting or during sleep Sleep lying on her back Contact the nurse-midwife if any bleeding occurs Apply cool compresses to the hemorrhoids
Elevate her hips on a pillow when resting or during sleep Apply cool compresses to the hemorrhoids
A nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which action should the nurse include in the plan? Discouraging social interaction, particularly at bedtime Encouraging at least one daytime nap Encouraging bedtime reading or listening to music Discouraging the use of a night light at bedtime
Encouraging bedtime reading or listening to music
The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. When should the nurse tell the mother the child should have dental examinations? Once a year Whenever a new primary tooth erupts Every 3 months Every 6 months
Every 6 months
A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? Supine Standing Hands and knees Prone
Hands and knees
A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman? Hypertension Pruritus Headache Vomiting
Headache
A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. Based on this finding, what does the nurse determine? The client needs to receive the hepatitis B series of vaccines The results are negative Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth The results indicate that the mother does not have hepatitis B
Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth
A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes that the menstrual pad was saturated in 15 minutes. What should be the nurse's next action? Remove the menstrual pad and replace with two pads. Place the client in a modified Sims' position. Immediately contact the primary health care provider. Do nothing. This is normal.
Immediately contact the primary health care provider.
A nurse is assessing language development in a toddler from a bilingual family. What should the nurse expect about the child's language development? Select all that apply. Is slower than expected Is developing as expected Could exhibit some lack of confidence related to communicating with others Will require assistance from a speech therapist Is more advanced than expected Will need more time to communicate with others
Is slower than expected Could exhibit some lack of confidence related to communicating with others Will need more time to communicate with others
A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if she performs which action? Uses a cotton-tipped swab to carefully clean inside the infant's nose Washes the diaper area first Uncovers only the body part being washed Washes the infant's chest first
Uncovers only the body part being washed
A nurse is discussing birth control methods with a client who is trying to decide which method to use. The nurse should focus on which major factor that will provide the motivation needed for consistent implementation of a birth control method? Family planning goals Personal preference Work and home schedules Desire to have children in the future
Personal preference
A nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which food item does the nurse tell the client contains the highest amount of folic acid? Oranges Lettuce Broccoli Pinto beans
Pinto beans
A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. Which action should the nurse take immediately? Notify the nurse-midwife or primary health care provider Perform a vaginal examination on the mother Insert a gloved finger into the mother's vagina to feel for cord compression Position the mother so that her hips are elevated
Position the mother so that her hips are elevated
A nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. After reading the client's record, what is the nurse's interpretation of this sign? That the cervix was seen to be violet Occurs at about 4 weeks of pregnancy That cervical softening is present Increased vascularity of the pelvic organs A positive sign of pregnancy A thinning of the cervix
That the cervix was seen to be violet Occurs at about 4 weeks of pregnancy Increased vascularity of the pelvic organs
A nurse is telling a pregnant client about the signs/symptoms that must be reported to the primary health care provider or nurse-midwife. The nurse tells the client that the primary health care provider or nurse-midwife should be contacted if which occurs? Puffiness of the face Urinary frequency Breast tenderness Morning sickness
Puffiness of the face
The mother of a 9-year-old child who is 5 feet 1 inch (155 cm) in height asks a nurse about car safety seats. What should the nurse tell the mother to use? Rear convertible seat Forward-facing car seat Rear seat using lap and shoulder seat belts Front booster seat
Rear seat using lap and shoulder seat belts
A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, what should the nurse tell the group about the infants? Experience frustration to allow an infant to cry for a while before meeting his or her needs Rely on the fact that their needs will be met Tolerate a great deal of frustration and discomfort to develop a healthy personality Ignore needs for short periods to develop a healthy personality
Rely on the fact that their needs will be met
The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. Which instruction should the nurse give the mother? To bring the infant to the pediatrician's office to be checked That the crust is to be expected as a normal part of healing That it could indicate a sign of an infection and that the infant's temperature should be checked every 2 hours To remove the crust, using a warm, wet face cloth and a mild soap
That the crust is to be expected as a normal part of healing
The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. What should the nurse tell the parents? To restrict any social privileges until the behavior stops That their daughter will need to see a child psychologist if the behavior continues That this type of behavior is usually the result of parents' spoiling a child That this is normal behavior for an adolescent
That this is normal behavior for an adolescent
A mother asks the nurse when her child should have his first dentist visit. What should the nurse tell the mother? Soon after the first primary tooth erupts, usually around 1 year of age At age 3 Twelve months after the first primary tooth erupts Just before beginning kindergarten
Soon after the first primary tooth erupts, usually around 1 year of age
A sexually active married couple, discussing birth control methods with the nurse, express the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest? Male condom Diaphragm Sterilization Spermicide
Sterilization
A nurse is monitoring a woman who is receiving oxytocin to induce labor. Which action should the nurse take first when suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor? Checking the woman's blood pressure and pulse Stopping the oxytocin infusion Increasing the intravenous (IV) rate of the nonadditive solution Notifying the nurse-midwife or primary health care provider
Stopping the oxytocin infusion
A nurse is determining the estimated date of delivery for a pregnant client, using Nägele's rule. Select the priority component(s) of Nägele's rule. Select all that apply. Subtracting 3 months Correcting the year Dividing the final number by 9 Determining the first day of last menstrual period Multiplying weeks by 2 Adding 7 days
Subtracting 3 months Correcting the year Determining the first day of last menstrual period Adding 7 days
A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz (2.9 kg). The nurse notes that the infant now weighs 13 lb (5.9 kg). Which action should the nurse take? Tell the mother that the infant's weight is increasing as expected Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes Tell the mother to decrease the daily number of feedings because the weight gain is excessive Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate
Tell the mother that the infant's weight is increasing as expected
A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn't know what to do. What should the nurse tell the mother? To separate her children during playtime That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity That if the behavior continues, she will need to bring her children to a child psychologist To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again
That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity
A female client asks a nurse about the advantages of using a female condom. Which should the nurse tell the client? That it offers protection against sexually transmitted infections (STIs) That it is 100% safe in preventing pregnancy That it does not have to be discarded after use and can be used several times before a new one must be obtained It can be used along with a male condom
That it offers protection against sexually transmitted infections (STIs)
A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. What should the nurse tell the client? She will be positioned on her back for the procedure The procedure takes about 2 hours A probe coated with gel will be inserted into the vagina That she may need to drink fluids before the test and may not void until the test has been completed
That she may need to drink fluids before the test and may not void until the test has been completed
The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse should tell the mother that which observation is a sign of physical readiness? The child no longer has temper tantrums. The child can eat using a fork and knife. The child can remove his or her own clothing. The child has been walking for 2 years.
The child can remove his or her own clothing.
A nurse reviews the health history of a client who will be seeing the primary health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? The client has hyperlipidemia. The client is being treated for hypertension. The client has type 2 diabetes mellitus. The client has been treated for breast cancer.
The client has been treated for breast cancer.
A nurse is caring for an older client who has a bronchopulmonary infection. Why should the nurse monitor the client's ability to maintain a patent airway? The normal aging process increases the production of surfactant The normal aging process increases respiratory system compliance The normal aging process decreases the number of alveoli and increases the function of those remaining The normal aging process decreases an older client's ability to clear secretions
The normal aging process decreases an older client's ability to clear secretions
A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. What should the nurse tell the client? She has developed immunity to the rubella virus The test results are normal The test will need to be repeated during the pregnancy She must have been exposed to the rubella virus at some point in her life
The test will need to be repeated during the pregnancy
A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted? There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side. The toes flare and the big toe is dorsiflexed. The infant turns to the side that is touched. The fingers curl tightly and the toes curl forward.
The toes flare and the big toe is dorsiflexed.
A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health? Select all that apply. The young adult has a sense of meaning and direction in life. The young adult verbalizes satisfaction with friendships. The young adult verbalizes unrealistic fears. The young adult is sensitive to criticism. The young adult verbalizes disappointment with life.
The young adult has a sense of meaning and direction in life. The young adult verbalizes satisfaction with friendships.
A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing mustard-yellow stools. What should the nurse tell the mother? Decrease the number of feedings by two per day. This is normal for breastfed infants. Stools should be solid and pale yellow to light brown. Monitor the infant for infection and, if a fever develops, contact the pediatrician.
This is normal for breastfed infants.
A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz (3.2 kg) about car safety. What should the nurse tell the mother? To secure the infant in the middle of the back seat in a rear-facing infant safety seat That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant
To secure the infant in the middle of the back seat in a rear-facing infant safety seat
A sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). What should the nurse tell the adolescent? Use of a latex condom can prevent transmission of STIs Use of a latex condom is a good method for preventing pregnancy A spermicide needs to be used along with a condom to prevent transmission of STIs The only way to prevent transmission of STIs is abstinence
Use of a latex condom can prevent transmission of STIs
A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. What should the nurse tell the mother to do? Use water and a cotton swab and rub the teeth Use a small amount of toothpaste and a soft-bristle toothbrush Use diluted fluoride and rub the teeth with a soft washcloth Dip the infant's pacifier in maple syrup so that the infant will suck
Use water and a cotton swab and rub the teeth
Intramuscular phytonadione 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it? Rectus femoris muscle Deltoid muscle Gluteal muscle Vastus lateralis muscle
Vastus lateralis muscle
A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. What should the nurse tell the clients? Drinking eight 8-oz (240 ml) glasses of fluid each day will reduce the risk of contracting influenza. It is best to do grocery shopping and other errands late in the day Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses They must stay in the house and ask a neighbor or family member to run their errands
Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses
A nurse is assessing the language development of a 9-month-old infant. Which developmental milestones does the nurse expect to note in an infant of this age? Select all that apply. The infant smiles and coos. Words begin to have meaning for the infant. The infant babbles single consonants. The infant says "Mama." The infant strings vowels and consonants together. The infant babbles.
Words begin to have meaning for the infant. The infant says "Mama." The infant strings vowels and consonants together.
A nurse helps a young adult conduct a personal lifestyle assessment. Why should the nurse carefully review the assessment with the young adult? Young adults ignore their risk for a serious illness Young adults are unable to afford health insurance Young adults are exposed to hazardous substances Young adults ignore physical symptoms and postpone seeking health care
Young adults ignore physical symptoms and postpone seeking health care
