OB/PEDS Hesi Review

A nurse is caring for a child who has increased intracranial pressure. Which of the following are appropriate actions by the nurse? (Select all that apply.) A. Suction the endotracheal tube every 2 hr. B. Maintain a quiet environment. C. Use two pillows to elevate the head. D. Administer a stool softener. E. Maintain body alignment.

B,D,E

A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. which of the following goals is the priority for the nurse to include in the plan of care? A. provide respite services for the parents B. improve the clients communication skills C. foster self-care activities D. modify the environment

D

The school nurse is conducting pediculosis capitals (head lice) assessments.which finding indicates a child has a positive head check?

white sacs attached to the hair shafts in the occipital area

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

260 ml

What is the preferred site of intramuscular injections for infants under three?

Vastus Lateralis

Which fetal heart rate (FHR) finding would concern the nurse during labor? a. Accelerations with fetal movement b. Early decelerations c. An average FHR of 126 beats/min d. Late decelerations

D

A child receives a prescription for amantadine 42 mg PO BID. Amantadine is available as a 50 mg/5 mL syrup. Using a supplied calibrated measuring device, how many mL should the nurse administer per dose? (round to nearest tenth)

0.5 mL

. A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30- hour labor. What is the priority nursing action for this client? A. Observe for signs of uterine hemorrhage B. Encourage direct contact with the infant C. Assess the blood pressure for hypertension D. Gently massage fundus every four hours

A

. A client who delivered a healthy newborn an hour ago asks the nurse when can she go home. Which information is most important for the nurse to provide the client? A. When there is no significant vaginal bleeding B. When ambulating to void does not cause dizziness C. After the vitamin K injection is given to the baby D. After the baby no longer demonstrates acrocyanosis

A

. A mother brings her 2 year old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child's oral temperature is 101.2 F. Which intervention should the nurse implement? a. Ask the mother if the child has had a runny nose b. Cleanse purulent exudate from the affected ear canal c. Apply a topical antibiotic to the periauricle area d. Provide parent education to prevent recurrence

A

. A mother brings her 3-week old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant's vomiting is projectile, and the child seems listless. Which additional assessment finding indicates the possibility of a life threatening complication? a. Irregular palpable pulse b. Hyperactive bowel sounds c. Underweight for age d. Crying without tears

A

A 5-year-old boy with leukemia is receiving chemotherapy through a peripherally inserted central catheter (PICC). Twenty minutes after the infusion is begun, the child feels dizzy and complains of itching. Which intervention should the nurse implement first? a. Discontinue the medication infusion b. Flush IV line with saline c. Obtain emergency resuscitation equipment d. Measure current blood pressure and pulse

A

A 9-week-old infant is scheduled for cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite? a. Red blood cell count of 2.3 million/mm3 b. White blood cell count of 10,000/mm3 c. Weight gain of 2 pounds since birth d. Urine specific gravity is 1.011

A

A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both his hands and feet. Which intervention should the nurse instruct the mother to implement first? a. Place the child in a quiet environment b. Make a list of foods that the child likes c. Encourage the parents to rest when possible d. Apply lotion to hands and feet

A

A client at 20 weeks gestation comes to the antepartum clinic complaining of vaginal warts (human papillomavirus). What information should the nurse provide this client? A. Treatment options, while limited due to the pregnancy, are available B. The client should be treated with Penicillin G C. This client should be treat with acyclovir (Zovirax) D. Termination of the pregnancy should be considered

A

A client at 33- weeks gestation is admitted with a moderate amount of vaginal bleeding and no contractions are noted on the external monitor. Which intervention should the nurse implement? A. Weight perineal pads B. Weight daily C. Measure intake and output D. Ambulate 15 minutes QID

A

A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings f the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first? A. Determine current cervical dilation B. Request placement of the epidural C. Give bolus of intravenous fluids D. Decrease the oxytocin infusion rate

A

A diabetic client delivers a full term large for gestational age infant who is jittery. What action should the nurse take first? A. Obtain a blood glucose level B. Administer oxygen C. Feed the infant glucose water (10%) D. Decrease environmental stimuli

A

A middle school male student was recently diagnosed with attention-deficit hyperactivity disorder (ADHD) and is having trouble with his grades. He is referred to the school nurse by the teacher because he continues to have learning problems. Which action should the school nurse take? a. Ask the parents to have the child seen by a clinical psychologist b. Ask the parents to become involved in helping the child with his homework c. Refer the child to the school counselor for educational testing d. Seek the advice of the school principle regarding the child's learning needs

A

A mother brings her 2-month old son to the clinic for a well-baby exam. During the assessment the nurse finds that the right testicle is not distended into the scrotum but the left is palpable. Which action should the nurse take? a. Ask if the right testis has been seen in the scrotum before b. Address possible concerns about the child's future fertility c. Schedule an IV pyelogram to validate presence of the testicle d. Prepare to obtain a catheterized urine specimen for culture

A

A mother brings her school-aged daughter to the pediatric clinic for evaluation of her anti-epileptic medication regimen. What information should the nurse provide to the mother? a. The medication dose will be tapered over a period of 2 weeks when being discontinued b. If seizures return, multiple medications will be prescribed for another 2 years c. A dose of valproic acid (Depakote) should be available in the event of status epilepticus d. Phenytoin (Dilantin) and phenobarbital (Luminal) should be taken for life

A

A school-aged male is brought to the school nurse after he was thrown off his bicycle into the trunk of a pine tree. The child's face and arms are speckled with embedded pine bark. He has copious tearing and complains that "there is stuff in my eyes." Which action should the nurse implement a. Patch both of child's eyes and send him to the family ophthalmologist b. Use sterile tweezers to lift bark specks from the sclera of each eye c. Instill pain relieving eye drops into each eye and keep head elevated d. Encourage the child to blink frequently to increase bilateral tearing in the eyes

A

An adolescent who is taking antiretroviral therapy for HIV infection arrives at the clinic for a follow up visit. Which information is most important for the nurse to obtain? a. Missed medication doses b. A 24-hour dietary recall c. Barrier contraceptive use d. Ingestion of illicit drugs

A

Calculated by Naegele's rule, a primigravida client is at 28 weeks gestation. She is moderately obese and carrying twins and the nurse measures her fundal height at 27 cm. During the previous visit 3 weeks ago, the fundal height measured at 28 cm. Based on these findings, what should the nurse conclude? A. Fundal height measurement may indicate intrauterine growth retardation B. The healthcare provider needs to be notified immediately since this fundal height measurement is greater than expected C. Confirm the fundal height measurement with another nurse D. Recognize this as a reasonable fundal height measurement for this client

A

Following the vaginal delivery of a large for gestation age (LGA) infant, a woman is admitted to the ICU due to post partum hemorrhaging. The client's medical record describes Jehovah's Witness notes as her religion. What action should the nurse take next? A. Inform the client of the critical need for a blood transfusion B. Obtain consent from the family to infuse packed red blood cells C. Clarify the clients wishes about receiving blood products D. Prepare to infuse multiple units of fresh frozen plasma

A

In developing a behavior modification program for an extremely aggressive 10 year old boy, what should the nurse do first? a. Determine what activities, foods, and toys the child enjoys b. Evaluate the child's previous reactions to punishment c. Provide the child with positive feedback d. Encourage other children on the unit to describe the token system

A

The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take? a. Document the finding b. Palpate scrotum for testicular descent c. Assess for bladder distension d. Auscultate bowel sounds

A

The nurse if caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus if firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first? A. Heart rate and blood pressure B. Abdominal contour and bowel sounds C. Urinary output and IV fluid intake D. Hemoglobin and Hematocrit

A

The nurse is caring for a 3-year old child who has been recently diagnosed with cystic fibrosis, which discharge instruction by the nurse is most important to promote pulmonary function? a. Chest physiotherapy should be performed before meals and at bedtime b. Cough suppressants can be used up to four times a day for relief c. Oxygen should be given through a nasal cannula between 4-6 L/min d. Exercise is discouraged in order to preserve pulmonary vital capacity

A

The nurse is caring for a postpartal patient who is exhibiting symptoms of spinal headaches 24 hours following delivery of a normal newborn. Prior to anesthesiologists's arrival on the unit, which action should the nurse perform? A. Place procedure equipment at bedside B. Apply an abdominal binder C. Cleanse the spinal injection site D. Insert an indwelling foley catheter

A

The nurse is performing a routine assessment of a 3-year old at a community health center. Which behavior by the child should alert the nurse to request a follow-up for a possible autistic spectrum disorder? a. Performs odd repetitive behaviors b. Shows indifference to verbal stimulation c. Strokes the hair of a hand held doll d. Has a history of temper tantrums

A

The nurse provides information about the human papilloma virus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit? a. Use of protective barriers during sexual activity prevents most strains of HPV infection b. Most adolescents are not honest about being sexually active c. Not all strains of HPV will be covered if given at a later date d. Immunity must be established to prevent future HPV infection and risk for cervical cancer

A

The parents of a 3-year old boy who has Duchenne muscular dystrophy ask, "How can our son have this disease? We are wondering if we should have any more children." What information should the nurse provide to parents? a. This is an inherited X-linked recessive disorder, which primarily affects male children in the family b. The striated muscle groups of males can be impacted by a lack of the protein dystrophin in their mothers c. The male infant had a viral infection that went unnoticed and untreated so muscle damage was incurred d. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles

A

While obtaining the vital signs of a 10 year old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2-3 minutes. Which assessment should the nurse implement? a. Inspect the posterior oropharynx b. Assess for teeth clenching or grinding c. Touch the tonsillar pillars to stimulate the gag reflex d. Ask the child to speak to evaluate change in voice tone

A

When caring for the child with Reye syndrome, the priority nursing intervention would be which of the following? a. Monitor intake and output. b. Prevent skin breakdown. c. Observe for petechial. d. Do range-of-motion exercises

A Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema.

An important nursing intervention when caring for a child who is experiencing a seizure would be which of the following? a. Describe and record the seizure activity observed. b. Restrain the child when seizure occurs to prevent bodily harm. c. Place a tongue blade between the teeth if they become clenched. d. Suction the child during a seizure to prevent aspiration.

A When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity.

Signs and symptoms that a woman should report immediately to her health care provider include (Select all that apply): a. Vaginal bleeding. b. Rupture of membranes. c. Heartburn accompanied by severe headache. d. Decreased libido. e. Urinary frequency.

A,B,C Vaginal bleeding, rupture of membranes, and severe headaches all are signs of potential complications in pregnancy. Clients should be advised to report these signs to the health care provider. Decreased libido and urinary frequency are common discomforts of pregnancy that do not require immediate health care interventions.

Medications used to manage postpartum hemorrhage (PPH) include (choose all that apply): a.Oxytocin b.Methergine c.Terbutaline d.Hemabate e. Magnesium sulfate

A,B,D

A mother of a 3-year old boy has just given birth to a new baby girl. The little boy asks the nurse, "why is my baby sister eating my mommy's breast?" how should the nurse respond? Select all that apply a. Remind him that his mother breastfed him too b. Clarify that breastfeeding is the mother's choice c. Reassure the older brother that it does not hurt his mother d. Explain that newborns get milk from their mothers in this way e. Suggest that the baby can also drink from a bottle

A,C,D

Lacerations of the cervix, vagina, or perineum are also causes of PPH. Which factors influence the causes and incidence of obstetric lacerations of the lower genital tract? (Select all that apply.) a. Operative and precipitate births b. Adherent retained placenta c. Abnormal presentation of the fetus d. Congenital abnormalities of the maternal soft tissue e. Previousscarring from infection

A,C,D,E

The mother brings her child with cerebral palsy in to the clinic and is afraid the child is having seizures as the child has the slow worm like movements in her arms and she drools when this occurs. The nurse explains to the mother that this is not a seizure but what type of activity?

Athetoid

. A term multigravida, who is receiving oxytocin (Pitocin) for labor augmentation, is requesting pain medication. Review of the clients record indicates that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the clients cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement? A. Medicate the client with an additional 1 mg of Stadol IV push B. Instruct the client to use deep breathing during a contraction C. Discontinue the Pitocin infusion D. Notify the healthcare provider

B

.After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborns diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first? A. Wipe away the spit-up and assist the mother with the diaper change B. Turn the newborn to the side and bulb suction the mouth and nares C. Sit the newborn up and burp by rubbing or patting the upper back D. Place the newborn in a position with the head lower than the feet

B

A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia. After returning to the postoperative neonatal unit, her RR and HR have increased during the last hour. Which intervention should the nurse implement? a. Notify the HCP of these findings b. Administer a PRN analgesic prescription c. Record the findings in the child's record d. Wrap the infant tightly and rock in rocking chair

B

A 3 hour old male infant's hands are feet are cyanotic, and he has an axillary temperature of 96.5 F, a respiratory rate of 40 breaths/min, and a heart rate of 165 beats/min. Which nursing intervention is best for the nurse to implement? A. Perform a heel- stick to monitor blood glucose level B. Gradually warm the infant under a radiant heart source C. Administer oxygen by mask at 2L/minute D. Notify the pediatrician of the infants unstable vital signs

B

A 3 year-old boy is receiving a weekly chemotherapy treatment. Which toy is best for the nurse to provide for this child? a. Bouncy ball b. Coloring book with crayons c. Duck that squeaks d. Remote-controlled care

B

A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents? a. Permanent life style changes need to be made to promote safety in the home b. The chorea or movements are temporary and will eventually disappear c. Muscle tension is decreased with fine motor project skills, so these activities should be encouraged d. Consistent discipline is needed to help the child control the movements

B

A child with Grave's disease who is taking propranolol (Inderal) is seen in the clinic. The nurse should monitor the child for which therapeutic response? a. Increased weight gain b. Decreased heart rate c. Reduce headaches d. Diminished fatigue

B

A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the hcp of the clients condition, what information is most important for the nurse to provide? A. Total amount of Pitocin infused B. Maternal Blood pressure C. Maternal Apical Pulse rate D. Time Pitocin infusion completed

B

A multiparous woman at 38-weeks gestation with a history of rapid progression of labor is admitted for induction due to signs and symptoms of preeclampsia. One hour after the Pitocin infusion is initiated, she complains of a headache. Her contractions are occurring every 1 to 2 minutes, lasting 60 to 75 seconds, and a vaginal exam indicates that her cervix is 90% effaced and dilated to 6 cm. What intervention is most important for the nurse to implement? A. Turn the client on her left side B. Discontinue the Pitocin infusion C. Prepare for immediate delivery D. Measure deep tendon reflexes

B

A new infant is receiving positive pressure ventilation after delivery. Based on which assessment finding should the nurse initiate chest compressions? A. Apgar score 7 B. Heart rate 54 C. Limp muscle tone D. Central cyanosis

B

A new mother, who is lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge? A. Avoid using lanolin-based nipple cream or ointment B. Continue prenatal vitamins with B12 while breast feeding C. Offer iron- fortified supplemental formula daily D. Weigh the baby weekly to evaluate the newborns growth

B

A woman who delivered a normal newborn 24 hours ago complains, " I seem to be urinating every hour or so. Is that ok?". Which action should the nurse implement? A. Catheterize the client for residual urine volume B. Measure the next voiding, then palpate the clients bladder C. Evaluate for normal involution, then massage the fundus D. Obtain a specimen for urine culture and sensitivity

B

An 8-year-old male client with nephrotic syndrome is receiving salt-poor human albumin IV. Which findings indicate to the nurse that the child is manifesting a therapeutic response? a. Decreased urinary output b. Decreased periorbital edema c. Increased periods of rest d. Weight gain 0.5 kg/day

B

During a follow up clinical visit a mother tells the nurse that her 5 month old son who had surgical correction for tetralogy of fallot has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement? a. Stimulate the infant to cry to produce cyanosis b. Auscultate heart and lungs while infant is held c. Evaluate infant for failure to thrive d. Obtain a 12-lead electrocardiogram

B

In assessing a 10-year old newly diagnosed with osteomyelitis, which information s most important for the nurse to obtain? a. Family history of bone disorders b. Recent occurrence of infection c. Cultural heritage and beliefs d. Occurrence of increased fluid intake

B

The mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant. The mother states, "My mother says I should put rice cereal in the baby's bottle now." The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior? a. Stops rooting when hungry b. Opens mouth when food comes her way c. Awakens once for nighttime feedings d. Gives up a bottle for a cup

B

The nurse is assessing a 38- week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extra-uterine life? A. Flexion of all four extremities B. Cries vigorously when stimulated C. Heart rate of 22 beats/minute D. A positive Babinki reflex

B

The nurse is conducting an admission assessment of an 11-month old infant with CHF who is scheduled for repair of restenosis of coarction of the aorta hat was repaired 4 days after birth. Findings include blood pressure higher in the arms than the lower extremities, pounding brachial pulses, and slightly palpable femoral pulses. What pathophysiologic mechanisms support these findings? a. The aortic semilunar valve obstructs blood flow into the systemic circulation b. The lumen of the aorta reduces the volume of the blood flow to the lower extremities c. The pulmonic valve prevents adequate blood volume into the pulmonary circulation d. An opening in the atrial septum causes a murmur due to a turbulent left to right shunt

B

The nurse is preparing a teaching plan for the parents of a 6 month-old infant with GERD. What instruction should the nurse include when teaching the parents measures to promote adequate nutrition? a. Alternate glucose water with formula b. Mix the formula with rice cereal c. Add multivitamins with iron to the formula d. Use water to dilute the formula

B

The parents of 15-month old boy tell the nurse that they are concerned because their son brings his spoon to his mouth but does not turn it over. What action should the nurse implement first? a. Discuss referral to an occupational therapist b. Question the parents about their concern c. Tell the parents to hold the spoon correctly in the child's hand d. Suggest longer mealtimes so the child can finish eating

B

The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond? A. Encourage the parents to report this to the healthcare provider B. Explain the newborns normal stepping reflex C. Acknowledge the parents observation D. Schedule the newborn for further neurological testing

B

When assessing a 5-year-old, which ability should the nurse expect the child to be developing at this age? a. Learning to ride a tricycle b. Tying shoelaces c. Buttoning clothes d. Cutting with scissors

B

Which topic is most important for the nurse to include in a nutrition teaching program for pregnant teenagers? A. Gestational diabetes B. Iron-deficieny anemia C. Excessive weight gain D. Elevated cholesterol

B

Probable signs of pregnancy are :

Ballottement, Chadwick's sign, Goodell's sign, Hegar's sign, uterine enlargement, Braxton Hicks contractions, positive blood pregnancy test

. The father of a 3- day- old infant who is breast feeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cried for no apparent reason. What information is most important for the nurse to provide to this father? A. A fluctuation in hormones in the early postpartum period can cause mood changes B. Recommend giving supplemental bottle feedings to the baby between breast feeding C. Contact the clinic if the behaviors continue for more than two weeks or become worse D. Tell the father to count the newborns number of soiled diapers over the next few days

C

A 16 year old with acute myelocytic leukemia is receiving chemotherapy (CT) via an implanted medication port at the outpatient oncology clinic. What action should the nurse implement when the infusion is complete? a. Administer Zofran b. Obtain blood samples for RBCs, WBCs, and platelets c. Flush mediport w/ saline and heparin solution d. Initiate an infusion of normal saline

C

A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol (Proventil). The child's mother tells the nurse that she uses this medication to open her son's airway when he is having trouble breathing. What is the nurse's best response? a. Recommend that the mother bring the child in for immediate evaluation b. Advise the mother that over-use of the drug may cause chronic bronchitis c. Assure the mother that she is using the medication correctly d. Confirm that the medication helps to reduce airway inflammation

C

A child who is admitted to the hospital with anemia is anxious, fearful, and hyperventilating. The nurse anticipates the child developing which acid base imbalance? a. Metabolic acidosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic alkalosis

C

A client who is receiving oxytocin (Pitocin) to augment early labor begins to experience hypersystolic or tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement? A. Reposition the fetal monitor transducers B. Alert the charge nurse to the patients condition C. Turn off the Pitocin infusion D. Decrease the rate of the Pitocin infusion

C

A male infant with bronchiolitis is brought to the clinic by his mother. The infant is congested and febrile with a capillary refill of 2 seconds. Which information should the nurse discuss with the mother? a. Encourage infant to play b. Limit the amount of oral intake c. Keep infant isolated from others d. Lay infant on back for naps

C

A mother brings her 8 mo. old baby boy to clinic bc he has been vomiting and had diarrhea for last 3 days. Which assessment is most important for nurse to make? a. Assess infant abdomen for tenderness b. Determine if the infant was exposed to a virus c. Measure the infant's pulse d. Evaluate the infant's cry

C

A nurse is teaching a class for mothers of premature infants, and is asked about "a shot for respiratory virus." What information about plaibizumab (Synagis) is correct? a. It is required immunization for all infants under the age of 3 months b. It must be repeated every two months to be effective c. It is recommended for infants who meet established high-risk criteria d. It provides protection for one year with a single injection

C

A primigravida at 36-weeks gestation, who is Rh negative, experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the health care provider? A. Fetal heart rate of 162 beats/minute B. Trace of protein in the urine C. Positive fetal hemoglobin test D. Mild contractions every 10 minutes

C

At 0600 while admitting a woman for a scheduled repeat c section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. What action should the nurse take first? A. Ensure preoperative lab results are available B. Start prescribed IV with Lactated Ringers C. Inform the anesthesia care provider D. Contact the clients obstetrician

C

During a routine physical exam, a male adolescent client tells the nurse, "sometimes, my mother gets angry because I want to be with my own friends." What is the best initial response by the nurse? a. Offer reassurance that his mother's concern is normal b. Determine is his friends are engaged in unsafe behaviors c. Ask about the client's response to his mother's anger d. Offer to discuss his concerns together with his mother

C

Following admission for cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with tetralogy of Fallot. What instruction should the nurse give the parents if their child becomes pale, cool, lethargic? a. Encourage oral electrolyte solution intake b. Assess the child to a recumbent position c. Contact their HCP immediately d. Provide a quiet time by holding or rocking the toddler

C

One hour after delivery, the nurse is unable to palpate the uterine fundus of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should the nurse implement next? A. Document number of pad changes in the last hour B. Increase the rate of the oxytocin infusion C. Palpate the suprapubic area for bladder distention D. Provide bedpan to void if unable to ambulate

C

One week after missing her menstrual period, a woman performs an OTC pregnancy test and it is positive. Which hormone is responsible for producing the positive result? A. Human placental lactogen B. Gonadotrophin-releasing hormone C. Human chorionic gonadotrophin D. Prostaglandin E2 Aplha

C

The health care provider hands a newborn to the nurse after a vaginal delivery. What action is most important for the nurse to implement? A. Allow the mother to touch the infant B. Complete a physical assessment C. Place the infant under a warming unit D. Determine the APGAR score

C

The nurse is assessing a postpartum client who delivered a 10 pound infant vaginally two hours ago. The clients fundus is 2 fingerbreadths above the umbilicus, deviated to the right side, and boggy. After the client voids 250 ml of urine using a bedpan, what action should the nurse implement? A. Re-evaluate the client in 15 minutes B. Assist the client to the bathroom to void C. Palpate the suprapubic region for distention D. Encourage the client to breastfeed

C

The nurse is caring for a newborn infant who was recently diagnosed with congenital heart defect. Which assessment finding warrants immediate intervention by the nurse? A. Sweating during feedings B. Weak peripheral pulse C. Bluish tinge to the tongue D. Increased respiratory rate

C

The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of 8 pounds at 36- weeks gestation. This amniocentesis is being performed to obtain which information? A. Presence of a neural tube defect B. Gender of the fetus C. Fetal lung maturity D. Chromosomal abnormalities

C

Vaginal prostaglandin gel is used to induce labor for a woman who is at 42 weeks gestation. Thirty minutes after insertion of the gel, the client complains of vaginal warmth, and is experiencing 90 second contractions with fetal heart rate decelerations. What action should the nurse implement first? A. Notify the hcp B. Assess the maternal vital signs C. Turn to a side-lying position D. Increase the IV infusion rate

C

While auscultating the lung sounds of a 5 year-old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. Which action is best for the nurse to take? a. Identify the antibiotic used to treat the pneumonia b. Report suspected child abuse to the proper authorities c. Inquire about the use of alternative methods of treatment d. Ask the parents if the child has been in a recent accident

C

A nurse caring for a laboring woman is cognizant that early decelerations are caused by:

Altered fetal cerebral blood flow Early decelerations are the fetus's response to fetal head compression. These are considered benign and interventions are not necessary.

END OF 1ST REVIEW

GREAT JOB!

With regard to the care management of preterm labor, nurses should be aware that:

The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.

Nurses need to understand the basic definition and incidence data regarding PPH. which statement regarding this condition is most accurate?

Traditionally, PPH has been classified as early PPH or late PPH with respect to birth

all of the following are likely complications that obese pregnant women may face except

a low-birthweight baby

What should nursing care of an infant with oral candidiasis (thrush) include?

Continue medication for the prescribed number of days

. The nurse is assessing a 35 week primigravida with a breech presentation who is expericing moderate uterine contraction every 3-5 minutes. During the examination the client tells the nurse, "I think my water just broke". Inspection of the perineal area reveals the umbilical cord protruding from the vagina. After activating the call bell system for assistance, what intervention should the nurse implement? A. Administer oxygen at 10 liters via face mask B. Don gloves and push the cord back into the vagina C. Wrap the umbilical cord with sterile gauze D. Position the client into a knee-chest position

D

9. The mother of a 14-year old who had a below-the-knee amputation for osteosarcoma tells the nurse that her child is angry and blaming her for allowing the amputation to occur. Which response is best for the nurse to provide? a. "I will ask the HCP for a psychiatric consult for your child" b. "This type of acting out behavior is normal for adolescents" c. "It is important to focus on your child's needs at this difficult time" d. "A reaction of anger is your child's attempt to cope with this loss"

D

A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment of the girl is most important for the nurse to obtain? a. Understanding of quality control process used to troubleshoot the pump b. Interpretation of fingerstick glucose levels that influence diet selections c. Knowledge of her glycosylated hemoglobin A1c levels for past year d. Ability to perform the pump for basal insulin with mealtime boluses

D

A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child's plan of care? a. Obtain vital signs at onset of fluid overload b. Change IV site dressing q3 days and PRN c. Monitor for signs of facial swelling or urticartia d. Assess for abdominal pain and vomiting

D

A client who is in active labor is receiving magnesium sulfate and begin to experience slurred speech and decreased reflexes. Which action should the nurse implement first? A. Obtain a serum magnesium level B. Measure the clients hourly urinary output C. Provide an emesis basin for vomiting D. Turn off the magnesium sulfate infusion

D

A male toddler is brought to the emergency center approximately three hours after swallowing tablets from his grandmother's bottle of digoxin (Lanoxin). What prescription should the nurse implement first? a. Administer activated charcoal b. Prepare gastric lavage c. Obtain a 12-lead electrocardiogram d. Give IV digoxin immune fab (Digibind)

D

A mother brings her 3 month old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family? a. The mother is a single parent and lives with her parents b. The mother states the baby is irritable during feedings c. The infant's formula has been changed twice d. The diaper area shows severe skin breakdown

D

A multiparous client at 38- weeks gestation is admitted to labor and delivery with a compliant of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears a baby crying. What action should the nurse take first? A. Inspect the clients perineum B. Turn on the infant warmer C. Notify a healthcare provider D. Push the call light for help

D

A newborn infant is receiving immunization prior to discharge. Which action should the nurse implement? A. Give the first dose of the vaccine for Rotavirus if any sibilings have diarrhea now B. Ask the mother if she wants the infant immunized for Haemophilus influenza C. Prepare the first dose for Diphtheria, tetanus toxoid and acellular pertussis (DTap) D. Obtain signed consent from the mother for administration of hepatitis B vaccine

D

An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone releasing hormone (LRHR) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment? a. "We should be sure to start our daughter on birth control pills" b. "Our daughter will be on this hormone treatment the rest of her life" c. "We should encourage her to dress in clothing that suits her sexual maturity level" d. "Sexual maturity differences between my daughter and her peers will disappear within a few years"

D

An adolescent's mother calls the primary HCP's office to inquire about the results of her daughter's serum test results that were drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry? a. Ask when the adolescent was last seen in the clinic b. Tell the mother to have the teenager call the clinic c. Since the serum samples were drawn last week provide the mother with the findings d. Explain that the information cannot be released without the 18-year olds permission

D

At 34- weeks gestation, a primigravida is assessed at her bimonthly clinic visist,. Which assessment finding is important for the nurse to report to the hcp? A. Increased appetite B. Fetal heart rate of 110 beats/minute C. Fundus below the xiphoid D. Weight gain of 7 pounds

D

During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. What action should the nurse implement? A. Assess neurological vital signs every 4 hours B. Apply direct pressure to the caput succedaneum (THIS ONE CROSSES THE SUTURE LINES) C. Submit a request for a stat CT scan of the head D. Notify the pediatrician of the cephalhematoma (THIS ONE DOES NOT CROSS THE SL & IS MORE CRITICAL)

D

The mother of a toddler reports to the nurse working in the pediatric clinic that her child has had a fever and sore throat for the past two days. The nurse observes several swollen red spots in the child's body, a few of which are fluid filled blisters. Which action should the nurse implement? a. Obtain fluid culture from blisters b. Administer a fever reducing salicylate c. Cover drainage vesicles with a dressing d. Implement transmission precautions

D

The mother of an 11-year old boy who has juvenile arthritis tells the nurse, "I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting." Which information is most important for the nurse to provide this mother? a. The child should be encouraged to rest when he experiences pain b. Encourage quiet activities such as watching television as a pain distracter c. The use of hot baths can be used as an alternative for pain medication d. Giving pain medication around the clock helps control the pain

D

The nurse is assessing a newborn who was precipitously delivered at 38 weeks gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement? A. Determine reactivity of neonatal reflexes B. Perform gestational age assessment C. Weight and measure the newborn D. Obtain a drug screen for cocaine

D

The nurse is counseling a client who is at 6 weeks gestation and is experiencing morning sickness, but does not want to take any drugs for this discomfort. Which herbal supplement is likely to help this client with the nausea she is experiencing? A. Ginko B. Chamomile C. Peppermint D. Ginger

D

The nurse is discussing involution with a post-partum client. Which statement best indicates that the client understands the effect of breastfeeding on the resumption of menstrual cycle? A. "My period will most likely return in 6 to 8 months" B. "I should expect my period to return in 6 to 8 weeks" C. "My period started as soon as the baby was born" D. "While I am breastfeeding, my period may be delayed"

D

What is one initial s/s of puerperal infection in the postpartum client? a. Fatigue continuing for longer than 1 week. b. Pain with voiding. c. Profuse vaginal bleeding with ambulation. d. Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth.

D

Which instructions should the nurse include in the discharge teaching plan of 7 year old girl with history of frequent urinary tract infections? a. Take frequent bubble baths b. Perform intermittent catheterization c. Check oral temperature daily d. Monitor for changes in urinary odor

D

While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the nurse take first? A. Prepare for a potential cesarean B. Allow the client to begin pushing C. Administer oxygen at 10/L by mask D. Change the maternal position

D

HELLP syndrome is associated with an increased risk for adverse perinatal outcomes, including

placental abruption, renal failure, cirrhosis, maternal and fetal death

Which assessment findings should the nurse note in a school age child with Duchene Muscular Dystrophy (DMD)?

-Lordosis -Gower sign -Waddling gait

During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. Which statement by the client reassures the nurse that teaching has been effective? a. "I will need to eat 600 more calories per day because I am pregnant." b ."I can continue with the same diet as before pregnancy as long as it is well balanced." c. "Diet and insulin needs change during pregnancy." d. "I will plan my diet based on the results of urine glucose testing."

C Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the third trimester, insulin needs may double or even quadruple.

A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this?

The parent is trying to restore normal balance through appropriate "hot" remedies In several cultures, including Filipino, Chinese, Arabic, and Hispanic, hot and cold describe certain properties completely unrelated to temperature. Respiratory conditions such as pneumonia are "cold" conditions and are treated with "hot" foods. The child may like broth but is unlikely to always prefer it to Jell-O, Popsicles, and juice. The evil eye applies to a state of imbalance of health, not curative actions. Chinese individuals, not Hispanic individuals, believe in chi as an innate energy

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 judgments 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 woman at 10 weeks of gestation who is seen in the prenatal clinic with presumptive signs and symptoms of pregnancy likely will have: a. Amenorrhea. b. Positive pregnancy test. c. Chadwick's sign. d. Hager's sign.

A Amenorrhea is a presumptive sign of pregnancy. Presumptive signs of pregnancy are felt by the woman. A positive pregnancy test, the presence of Chadwick's sign, and the presence of Hager's sign all are probable signs of pregnancy.

A nurse is taking care of a 10-year-old child that weighs 30 kg. The doctor has ordered azithromycin PO 300 mg x 1 dose. Azithromycin comes in an oral suspension 100mg/5 mL in a 15 mL bottle. According to the drug handbook for children 2-15 years of age, 10 mg/kg/day but not to exceed 500 mg/day. How many milliliters should be given?

3 ml

A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions by the nurse is appropriate? A. Place the client on NPO status. B. Prepare the client for a liver biopsy. C. Position the client dorsal recumbent. D. Put the client in a protective environment

A

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal, and the estimated blood loss (EBL) was approximately 1500 mL. When assessing the woman's vital signs, the nurse would be concerned to see: a. Temperature 37.9° C, heart rate 120, respirations 20, blood pressure (BP) 90/50. b. Temperature 37.4° C, heart rate 88, respirations 36, BP 126/68. c. Temperature 38° C, heart rate 80, respirations 16, BP 110/80. d. Temperature 36.8° C, heart rate 60, respirations 18, BP 140/90.

A

Which of the following positions would be least effective when gravity is desired to assist in fetal descent?

Lithotomy

A multigravida client in labor is receiving oxytocin Pitocin 4mu/minute to help promote an effective contraction pattern. The available solution is Lactated Ringers 1,000 ml with Pitocin 20 units. The nurse should program the infusion pump to deliver how many ml/hr?

12

Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. 1. Maintain the child in a semiprivate room. 2. Reduce exposure to environmental organisms. 3. Use strict aseptic technique for all procedures. 4. Ensure that anyone entering the child's room wears a mask. 5. Apply firm pressure to a needle stick area for at least 10 minutes.

2,3,4

A 32- week primigravida who is in preterm labor receives a prescription for an infusion of D5W 500 ml with magnesium sulfate 20 grams at 1 gram/hour. How many ml/hour should the nurse program the infusion pump?

25

A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make?

Normal bone growth can be affected

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 Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midf oot supination, hind foot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

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 pedals 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 2-year-old girl is brought to the clinic by her 17 year old mother. When the nurse observes that the child is drinking sweetened soda from her bottle, what information should the nurse discuss with this mother? Select all that apply. a. A 2-year old should be speaking in 2 word phrases b. Dental caries are associated with drinking soda c. Drinking soda is related to childhood obesity d. Toddlers should be sleeping 10 hours a night e. Toddlers should be drinking from a cup by age 2

B,C,E

Nurses should be aware that chronic hypertension:

Can occur independently of or simultaneously with gestational hypertension.

The nurse is counseling the parents of a 12-year-old child with Duchenne muscular dystrophy about problems that may develop during adolescence. What body system does the nurse expect will be affected?

Cardiopulmonary Muscle degeneration is advanced in the adolescent with Duchenne muscular dystrophy. The disease process involves the diaphragm, auxiliary muscles of respiration, and the heart, resulting in life threatening respiratory infections and heart failure. Central nervous system function is not affected by Duchenne muscular dystrophy; nor is the integumentary system. Nutritional problems related to the gastrointestinal system are less significant than cardiopulmonary problems.

A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching?

I will record the highest reading of three attempts

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions should the nurse include in the plan of care?

Implement seizure precautions.

An 11 year-old child has a recurrence of Ewing sarcoma and is verbalizing wanting to stop all treatments. The nurse is aware that the best ethical practice would be which of the following plan?

Plan a meeting with the parents, child, and the medical team to provide an opportunity to discuss the child's concerns.

A 16-year-old boy comes into the office of the school nurse complaining of left hip pain that began when playing basketball in gym class. The boy is in the 85th percentile for height and weight. He complains of increased pain with weight bearing. The nurse observes out-toeing of the left leg with ambulation. Which nursing action is a priority?

Refer the boy to the emergency department.

A patient recently came into the Emergency Department with a diagnosis of Guillain-Barre Syndrome (GBS). What is the priority system to initially monitor for this patient?

Respiratory

A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to:

Stimulate fetal surfactant production.

The nurse is preparing to assess a 10-month-old infant. He is sitting on his father's lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?

Initiate a game of peek-a-boo

A 12 year-old comes into the clinical with left thigh pain and a lump over the distal femur. The nurse is aware that these symptoms can be linked to which of the following medical problems.

Osteosarcoma

The most effective and least expensive treatment of puerperal infection is prevention. What is the most important strategy for the nurse to adopt?

Strict aseptic technique, including hand washing by all health care personnel

The 17 year-old Asian patient comes to the clinic with a butterfly rash on the face, photosensitivity, and recently had strep throat. What diagnosis would you expect the doctor to make?

Systemic Lupus Erythematosus (SLE)

A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include 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 HCP's prescriptions for the amount of weight to be applied

4

A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to: a. establish venous access. b. perform fundal massage. c. prepare the woman for surgical intervention. d. catheterize the bladder.

B The initial management of excessive after birth bleeding is firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, the initial intervention would be fundal massage.

As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or haslate decelerations or loss of variability is nonreassuring and is associated with: a. Hypotension. b. Cord compression. c. Maternal drug use. d. Hypoxemia

D

Nurses should know some basic definitions concerning preterm birth, preterm labor, and low birth weight. For instance:

Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy. Before 20 weeks, it is not viable (miscarriage); after 37 weeks, it can be considered term. Although these terms are used interchangeably, they have different meanings: preterm birth describes the length of gestation (37 weeks) regardless of weight; low birth weight describes weight only (2500 g or less) at the time of birth, whenever it occurs. Low birth weight is anything less than 2500 g, or about 5.5 pounds. In 2003 the preterm birth rate in the United States was 12.3%, but it is increasing in frequency.

Magnesium sulfate is given to women with preeclampsia and eclampsia to:

Prevent and treat convulsions.

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure? Choose all that apply. A) Place the woman in a supine position. B) Place the woman in a lateral position. C) Increase intravenous (IV) fluids. D) Continuous Fetal Monitor E) Administer ephedrine per MD order

B,C,E

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? "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

Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for: a. Macrosomia b. Congenital anomalies of the central nervous system c. Preterm birth d. Low birth weight

A Fetal macrosomia is a risk to the fetus of a mother with GDM. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies.

The exact cause of preterm labor is unknown and believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Select the type of infection that has not been linked to preterm births. a. Viral b. Periodontal c. Cervical d. Urinary tract

A

The most critical nursing action in caring for the newborn immediately after birth is: a. Keeping the newborn's airway clear. b. Fostering parent-newborn attachment. c. Drying the newborn and wrapping the infant in a blanket. d. Administering eye drops and vitamin K.

A

The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for? A. Cardiac arrhythmia B. Hypostatic pneumonia C. Heart failure D. Rapidly increasing blood pressure

A

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage (PPH) is most likely caused by: a. Subinvolution of the placental site. b.Defective vascularity of the decidua. c.Cervical lacerations. d.Coagulation disorders.

A

When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign a. Dilation of the cervix. b. Descent of the fetus. c. Rupture of the amniotic membranes. d. Increase in bloody show. that uterine contractions are effective would be

A

When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's risk for ---------------- has increased a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension

A

Which statement about pregnancy is accurate? a. A normal pregnancy lasts about 10 lunar months. b. A trimester is one third of a year. c. The prenatal period extends from fertilization to conception. d. The estimated date of confinement (EDC) is how long the mother will have to be bedridden after birth.

A A lunar month lasts 28 days, or 4 weeks. Pregnancy spans 9 calendar months but 10 lunar months. A trimester is one third of a normal pregnancy, or about 13 to 14 weeks. The prenatal period covers the full course of pregnancy (prenatal means before birth). The EDC is now called the EDB, or estimated date of birth. It has nothing to do with the duration of bed rest.

Your patient is being induced because of her worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active despite several hours of oxytocin administration. She asks the nurse, "Why is it taking so long?" The most appropriate response by the nurse would be: a. "The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor." b. "I don't know why it is taking so long." c." The length of labor varies for different women." d." Your baby is just being stubborn."

A Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor. The amount of oxytocin needed to stimulate labor may be more than that needed for the woman who is not receiving magnesium sulfate.

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's intravenous fluid for a preprocedural bolus. a. She has thrombocytopenia. b .She is too far dilated. c. She is anemic. d. She is septic.

A She reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dL, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman She has thrombocytopenia

Four-year-old David is placed in Buck extension traction for Legg-Calve-Perches disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse. What should the nurse do first? a. Notify the practitioner of the changes noted. b. Give the child medication to relieve the pain. c. Reposition the child and notify physician. d. Chart the observations and check the extremity again in 15 minutes.

A The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner.

The perinatal nurse is caring for a woman in the immediate post birth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is: a. uterine atony. b. uterine inversion. c. vaginal hematoma. d. vaginal laceration.

A Uterine atony is marked hypotonia of the uterus. It is the leading cause of after birth hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this patient's bleeding. Further, if the woman were experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding for vaginal hematoma is pain, not the presence of profuse bleeding. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus

Five essential components of any fetal heart rate (FHR) tracing must be evaluated regularly. These include (choose all that apply): a. Baseline rate b. Baseline variability c. Accelerations d. Decelerations e. Changes or trends over time f. Frequency of contractions

A,B,C,D,E The five essential components of the FHR tracing that must be evaluated regularly are baseline rate, baseline variability, accelerations, decelerations, and changes or trends over time. Whenever one of these five essential components is assessed as abnormal, corrective measures must immediately be taken.

Emergency conditions during labor that would require immediate nursing intervention can arise with startling speed. Which situations are examples of such an emergency? (Select all that apply.) a. Nonreassuring or abnormal FHR pattern b. Inadequate uterine relaxation c. Vaginal bleeding d. Prolonged second stage e. Prolapse of the cord

A,B,C,E A nonreassuring or abnormal FHR pattern, inadequate uterine relaxation, vaginal bleeding, infection, and cord prolapse all constitute an emergency during labor that requires immediate nursing intervention. A prolonged second stage of labor after the upper limits for duration is reached. This is 3 hours for nulliparous women and 2 hours for multiparous women

The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy in 2 hours. Which of the following actions should the nurse include in the child's postoperative care plan? (Select all that apply.) a. Notify the surgeon if the child swallows frequently. b. Apply a heat collar to the child for pain relief. c. Place the child on the abdomen until fully wake. d. Allow the child to have diluted juice after the procedure. e. Encourage the child to cough frequently.

A,C,D Frequent swallowing is a sign of bleeding in children after a tonsillectomy. The child should be placed on the abdomen or the side to facilitate drainage.

A nurse is planning to use an interpreter during a health history interview of a nonEnglish speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter (Select all that apply)? a. Elicit one answer at a time. b. Interrupt the interpreter if the response from the family is lengthy. c. Comments to the interpreter about the family should be made in English. d. Arrange for the family to speak with the same interpreter, if possible. e. Introduce the interpreter to the family.

A,D,E When using an interpreter, the nurse should pose questions to elicit only one answer at a time, such as: "Do you have pain?" rather than "Do you have any pain, tiredness, or loss of appetite?" Refrain from interrupting family members and the interpreter while they are conversing. Introduce the interpreter to family and allow some time before the interview for them to become acquainted. Refrain from interrupting family members and the interpreter while they are conversing. Avoid commenting to the interpreter about family members because they may understand some English.

Preeclampsia is a unique disease process related only to human pregnancy. The exact cause of this condition continues to elude researchers. The American College of Obstetricians and Gynecologists has developed a comprehensive list of risk factors associated with the development of preeclampsia. Which client exhibits the greatest number of these risk factors?

An African-American client who is 19 years old and pregnant with twins

The child has been complaining of joint pain in the knees and jaw for the last 6 weeks, both joints are swollen and warm to touch, but not red. The physician is ordering blood to rule out Junior Idiopathic Arthritis. Which of the following lab tests would the nurse expect the physician to order?

Antinuclear antibodies CBC with differential

Phenylketonuria (PKU) is a genetic disease that results in the bodys inability to correctly metabolize: a. glucose. b. phenylalanine. c. phenyl ketones. d. thyroxine.

B

Prostiglandin has been ordered for a pregnant woman at 43 week of gestation. The nurse recognized that this medication is administered to: a. To stimulate the amniotic membranes to rupture b. To ripen the cervix in preparation for labor induction c. To enhance uteroplacental perfusion in an aging placenta d. To increase amniotic fluid volume

B

The nurse providing care for the laboring woman realizes that variable fetal heart rate (FHR) decelerations are caused by: a. Altered fetal cerebral blood flow. b. Umbilical cord compression. c. Uteroplacental insufficiency. d. Fetal hypoxemia.

B

What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken. a. Call the provider, reposition the mother, and perform a vaginal examination. b. Reposition the mother, increase intravenous(IV) fluid, and provide oxygen via face mask. c. Administer oxygen to the mother, increase IV fluid, and notify the care provider. d. Perform a vaginal examination, reposition the mother, and provide oxygen via face mask

B

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? A. The child exhibits nasal flaring and bradycardia. B. The child is leaning forward, with the chin thrust out. C. The child has a low-grade fever and complains of a sore throat. D. The child is leaning backward, supporting himself or herself with the hands and arms.

B Epiglottitis is a bacterial form of croup. A primary concern is that it can progress to acute respiratory distress.

1. A woman's obstetric history indicates that she is pregnant for the fourth time and all of her children from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another child was born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system? a. 3-1-1-1-3 b .4-1-2-0-4 c . 3-0-3-0-3 d. 4-2-1-0-3

B The correct calculation of this woman's gravidity and parity is 4-1-2-0-4. The numbers reflect the woman's gravidity and parity information. Using the GPTAL system, her information is calculated as: G: The first number reflects the total number of times the woman has been pregnant; she is pregnant for the fourth time. T: This number indicates the number of pregnancies carried to term, not the number of deliveries at term; only one of her pregnancies has resulted in a fetus at term. P: This is the number of pregnancies that resulted in a preterm birth; the woman has had two pregnancies in which she delivered preterm. A: This number signifies whether the woman has had any abortions or miscarriages before the period of viability; she has not. L: This number signifies the number of children born that currently are living; the woman has four children.

The nurse has received a report regarding a client in labor. The woman's last vaginal examination was recorded as 3 cm, 30%, and -2. What is the nurse's interpretation of this assessment? a. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines. b. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. c. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines. d. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

B The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman, the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines.

Complications and risks associated with cesarean births include (Select all that apply): a. Placental abruption. b. Wound dehiscence. c. Hemorrhage. d. Urinary tract infections. e. Fetal injuries.

B,C,D,E Placental abruption and placenta previa are both indications for cesarean birth and are not complications thereof. Wound dehiscence, hemorrhage, urinary tract infection, and fetal injuries are all possible complications and risks associated with delivery by cesarean section.

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 A. Use the fingertips to lift the cast while it is drying B. Keep small toys and sharp objects away from the cast C. Use a paddle ruler or another padded object to scratch the skin under the cast if it itches D. Place a heating pad on the lower end of the cast and over the fingers if the finders feel cool E. Elevate the extremity on pillows for the first 24-48 hours after casting to prevent swelling F. Contact the HCP if the child complains of numbness or tingling in the extremity

B,E,F

A nurse is caring for a school-age client who possibly has Reye syndrome. Which of the following is a risk factor for developing Reye syndrome? A. Recent history of infectious cystitis caused by Candida B. Recent history of bacterial otitis media C. Recent episode of gastroenteritis D. Recent episode of Haemophilus influenzae meningitis

C

A woman arrives at the clinic for a pregnancy test. Her last menstrual period (LMP) was February 14, 2011. Her expected date of birth (EDB) is: a. September 17, 2011 b. November 7, 2011 c. November 21, 2011 d. December 17, 2011

C

The nurse is conducting a staff in-service on sickle cell anemia. Which describes the pathologic changes of sickle cell anemia? a. Sickle-shaped cells carry excess oxygen. b. Sickle-shaped cells decrease blood viscosity. c. Increased red blood cell destruction occurs. d. Decreased adhesion of sickle-shaped cells occurs.

C

The nurse recognizes that a woman is in true labor when she states: a. "I passed some thick, pink mucus when I urinated this morning." b. "My bag of waters just broke." c. "The contractions in my uterus are getting stronger and closer together." d. "My baby dropped, and I have to urinate more frequently now."

C

While taking a diet history, the nurse might be told that the expectant mother has cravings for ice chips, cornstarch, and baking soda. This represents a nutritional problem known as: a. Preeclampsia. b. Pyros is. c. Pica. d. Purging.

C

A laboring woman has received meperidine (Demerol) intravenously (IV), 90 minutes before giving birth. Which medication should be available to reduce the postnatal effects of meperidine on the neonate? a.Fentanyl (Sublimaze) b.Promethazine (Phenergan) c.Naloxone (Narcan) d.Nalbuphine (Nubain)

C An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists, such as naloxone (Narcan), can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl (Sublimaze), promethazine (Phenergan), and nalbuphine (Nubain) do not act as opioid antagonists to reduce the postnatal effects of meperidine on the neonate.

A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman: a. Discusses her labor and birth experience excessively. b. Believes that her baby is more attractive and clever than any others. c. Has not given the baby a name. d. Has a partner or family members who react very positively about the baby.

C If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis could be Impaired parenting related to a long, difficult labor or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the baby's sex. The client may voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.

An appropriate nursing intervention when caring for an unconscious child would be which of the following? a. Change the child's position infrequently to minimize the chance of increased ICP. b. Avoid using narcotics or sedatives to provide comfort and pain relief. c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. d. Give tepid sponge baths to reduce fever, since antipyretics are contraindicated

C Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema.

Home care is being considered for a young child who is ventilator-dependent. Which factor is most important in deciding whether home care is appropriate? a. Level of parents' education b. Presence of two parents in the home c. Preparation and training of family d. Family's ability to assume all health care costs

C One of the essential elements is the family's training and preparation. The family must be able to demonstrate all aspects of care for the child.

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should know that: a. Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own. b. Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because they are consuming more sugar. c. During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. d. Maternal insulin requirements steadily decline during pregnancy.

C Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own insulin around the tenth week

A child steps on a nail and sustains a puncture wound of the foot. Which of the following is the most appropriate method for cleansing this wound? a. Wash wound thoroughly with chlorhexidine. b. Wash wound thoroughly with povidone-iodine. c. Soak foot in warm water and soap. d. Soak foot in solution of 50% hydrogen peroxide and 50% water.

C Puncture wounds should be cleansed by soaking the foot in warm water and soap

Nursing interventions for the child after a cardiac catheterization should include which actions? (Select all that apply.) A. Allow ambulation as tolerated. B. Monitor vital signs every 2 hours. C. Assess the affected extremity for temperature and color. D. Check pulses above the catheterization site for equality and symmetry. E. Remove pressure dressing after 4 hours. F. Maintain a patent peripheral intravenous catheter until discharge.

C,F

51. A woman has come to the clinic for preconception counseling because she wants to start trying to get pregnant in 3 months. She can expect the following advice: a. "Discontinue all contraception now." b. "Lose weight so that you can gain more during pregnancy." c. "You may take any medications you have been taking regularly." d. "Make sure that you include adequate folic acid in your diet."

D

A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes. She is groaning and perspiring excessively; she states that she did not attend childbirth classes. What is the optimal intervention for the nurse to provide at this time? a.Notify the woman's health care provider. b.Administer the prescribed narcotic analgesic. c.Assure her that her labor will be over soon. d.Assist her with simple breathing and relaxation instructions.

D By reducing tension and stress, both focusing and relaxation techniques will allow the woman in labor to rest and conserve energy for the task of giving birth.

Pancreatic enzymes are administered to the child with cystic fibrosis. What nursing consideration should be included in the plan of care? A. Give pancreatic enzymes between meals if at all possible. B. Do not administer pancreatic enzymes if child is receiving antibiotics. C. Decrease dose of pancreatic enzymes if child is having frequent, bulky stools. D. Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at beginning of meal.

D Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal. Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or swallowed whole.

What is the most important thing for a nurse to teach parents of a child with Duchenne Muscular Dystrophy to do for their schoolaged-child? A. Maintain high caloric diet B. Institute seizure precautions C. Restrict the use of larger muscles D. Perform range of motion exercises

D ROMs are essential to help achieve primary objectives of maintaining optimal muscle function for as long as possible and preventing the development of contractures. High caloric diet would make them fat, which would push them to a wheel-chair faster than you can say "fat guy in a little coat". Seizures have nothing to do with duchenne, and restricting large muscles could result is disuse atrophy and contractures.

A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies would the nurse implement to promote the infant's growth and development? A. Tie colorful latex balloons to the side of the crib. B. Provide a small electronic toy. C. Change the infant's diaper as soon as soiling occurs. D. Allow infant to stand in the crib

D The infant should not be restricted from normal activities. The infant can be held and allowed to walk in a cast or orthotic device. Allowing the child to participate in normal developmental activities will promote growth and development.

An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of: a. Air embolism. b. Allergic reaction. c. hemolytic reaction d. Circulatory overload.

D The signs of circulatory overload include distended neck veins, hypertension, crackles, dry cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Allergic reactions are manifested by urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema. Hemolytic reactions are characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and renal failure.

characteristics of physical development of a 30-month-old child are (Select all that apply): A. anterior fontanel is open. B. birth weight has doubled. C. genital fondling is noted. D. sphincter control is achieved. E. primary dentition is complete.

D,E Sphincter control in preparation for bowel and bladder control is usually achieved by 30 months of age. Primary dentition is usually completed by 30 months of age. Anterior fontanel closes between 12-18 months of age. Birth weight should double at 5-6 months of age and quadruple by 2½ years of age. Genital fondling is not a characteristic of physical development of this age group. This is part of the development of gender identity.