IM5 Assessment and Intervention Practice Questions

Which finding on physical assessment of a neonate would indicate the need for further observation and examination? A. Epstein Pearls B. Cyanotic hands and feet C. Babinski reflex D. Low-set ears

D. Low-set ears

A nurse explains the physical sensation that a 13-year-old client will feel when a needle punctures the skin to draw blood. What instructional method would the nurse use? A. Analogy B. Role play C. Demonstration D. Preparatory instruction

D. Preparatory instruction

A nurse in the newborn nursery has just received report. Which of the following infants should the nurse see first? A. A 2-day-old who is lying quietly alert with a heart rate of 185 B. A 1-day-old who is crying and has a bulging anterior fontanelle C. A 12-hour-old who is being held, with respirations that are 45 breaths per minute and irregular D. 5-hour-old who is sleeping and whose hands and feet are blue bilaterally

A. A 2-day-old who is lying quietly alert with a heart rate of 185

A nurse in the birthing room is assessing a newborn. Which newborn characteristic should be assigned an Apgar value of 2? A. A strong cry B. Legs and arms slightly flexed C. Body pink and extremities blue D. A heart rate of ninety beats per minute

A. A strong cry

After surgery a 2-month-old infant is returned to the pediatric unit with an intravenous infusion running and a nasogastric tube in place. What is the initial nursing action? A. Assessing the infant's status B. Giving the infant a mild sedative C. Connecting the nasogastric tube to wall suction D. Placing the intravenous tubing through an infusion pump

A. Assessing the infant's status

While preparing to apply the identification bracelets to a newborn, the nurse notices that the spelling of the last name does not match the information on the mother's band. What should the nurse do? A. Refrain from applying the bands because all details do not match the mother's band. B. Apply the bands as long as the medical record information is correct. C. Bundle the newborn and transport him or her to the nursery to obtain new bands. D. Tape the footprint sheet to the newborn because it carries all the accurate information.

A. Refrain from applying the bands because all details do not match the mother's band.

A 16-year-old single mother of a 1-year-old infant and the infant's grandmother bring the baby to the emergency department and report that the infant accidentally fell down the stairs. The nurse knows that a consent form for treatment should be signed. Who has the responsibility for signing the consent? A. The mother, despite her age B. No one, because this is an emergency C. The grandmother, because she is a relative D. Family court, because the mother is a minor

A. The mother, despite her age

A 7-year-old boy who is about to have an intravenous line inserted cries out that he is afraid of IVs. What is the nurse's most therapeutic response? A."Tell me what frightens you." B. "It's just a little prick in the arm." C."You're a big boy; this will hardly hurt." D."Come on—there's no reason to be afraid."

A."Tell me what frightens you."

The nurse is using a bulb syringe to suction a neonate after delivery. The most appropriate technique for bulb syringe suction is to A. Compress bulb after insertion B. Clear mouth before nasal passages C. Use two bulb syringes, one for mouth and one for nose D. Use mechanical suctioning it is more efficient

B. Clear mouth before nasal passages

Immediately after birth, a newborn's mouth and nose are suctioned with the bulb syringe. The newborn has a weak cry and is hypotonic. What should the nurse do first? A. Repeat suctioning of the oropharyngeal area with an appropriate suction catheter. B. Reposition the airway and assess respirations. C. Perform a rapid gestational age assessment to see whether the newborn is preterm. D. Administer 100% blow-by oxygen.

B. Reposition the airway and assess respirations.

The initiation of breathing in a newborn helps to establish? A. maintaining core temperature B. conversion to neonatal circulation C. opening of fetal shunts D. passage of meconium

B. conversion to neonatal circulation

The nurse is in a delivery room that has a temperature of 23.9°C (75°F). After delivery of a stable, term newborn, the nurse assesses vital signs and discovers that the newborn's temperature is 37.1°C (98.8°F) How should the nurse respond? A. Turn off the warmer and increase the temperature in the room. B. Recognize that the newborn is septic and immediately contact the neonatologist. C. Place the newborn in skin-to-skin contact with the mother to initiate breastfeeding. D. Call the pediatrician and obtain an order for acetaminophen.

C. Place the newborn in skin-to-skin contact with the mother to initiate breastfeeding.

A nurse must restart a peripheral intravenous infusion on a hospitalized 5-year-old child. What should the nurse do to promote the child's sense of security? A. Inform the child that it will feel like a bee sting. B. Ask the child if the parents should leave the room. C. Take the child to the treatment room for the procedure. D. Tell the child that it is important to have a new IV started.

C. Take the child to the treatment room for the procedure.

The nurse is completing a newborn assessment and counting the infant's cord vessels. In a normal newborn umbilical cord there are: A. Two vessels: one vein and one artery B. Three vessels: two veins and one artery C. Three vessels: one vein and two arteries D. Four vessels: two veins and two arteries

C. Three vessels: one vein and two arteries