PNE 136/Maternal/Final PrepU
Asthma Treatment
First elevate the HOB (head of bed) to expand the diaphragm, assess 02 sat, apply 02, then determine trigger. *If the child is in distress (tachypneic, etc.) administer bronchodilator before antibiotics-open airway first to facilitate breathing
Sickle Cell Disease
Genetic disorder in which red blood cells have abnormal hemoglobin molecules and take on an abnormal shape. Sickling causes RBC cells to change shape, unable to pass through capillaries correctly, leads to vaso-occlusion. *May lead to life-threatening situations such as CVA
The nurse is teaching a breastfeeding class for nursing students. Teaching has been effective when the student can cite which maternal conditions in which breastfeeding is contraindicated? Select all that apply. HIV Chlamydia Chemotherapy Illegal drug use Active untreated tuberculosis
HIV Chemotherapy Illegal drug use Active untreated tuberculosis
The nurse is assessing the external fetal monitor and notes the following: fetal heart rate of 175 beats/min, decrease in variability, and late decelerations. Which action should the nurse take first? Continue to monitor the pattern every 15 minutes Administer fluids Notify the health care provider Have the client change position
Have the client change position
Cystic Fibrosis
Hereditary, autosomal recessive trait, both parents must be carriers of the gene Principal diagnostic test: sweat chloride test using pilocarpine iontophoresis method. *Sweat-induced in a localized area of skin using a small electric current and topically applied pilocarpine *60 mEq/L is positive Treatment: To relieve thick secretions: encourage oral fluids, chest PT, humidified 02 supplementation, observe resp status/frequent 02 sat monitoring (hourly or more)
The nurse is caring for a client placed on droplet precautions. Which teaching is a priority for the nurse to reinforce for the caregivers? How to use and apply personal protective equipment. Appropriate methods to clean and disinfect the home. How to prevent the client from becoming lonely while hospitalized. The unit policy for visitors of clients on droplet precautions.
How to use and apply personal protective equipment.
The nurse is caring for a newborn with fetal alcohol spectrum disorder. The nurse knows that the newborn will demonstrate: Hyperactivity A large head circumference Lethargy Hyperglycemia
Hyperactivity
The nurse is teaching a group of first time parents who are being discharged with their newborns. One parent asks the nurse what to do if the child has a temperature. After conducting teaching regarding how to care for a child with an elevated temperature, the caregivers make the following statements. Which statement would indicate a need for further teaching? I dont plan to give my child medications, but the pediatrician might tell us to give our child acetaminophen every 4 to 6 hours if she has a fever. Giving extra fluids is the way I have always heard to lower a temperature. If my child starts to shiver, I will know that what I am doing is working and that her fever will soon come down. A rectal temperature above 102.5F (39.1C) should be lowered.
If my child starts to shiver, I will know that what I am doing is working and that her fever will soon come down.
The nursing instructor is conducting a class exploring the care of the neonate right after birth. The instructor determines the class is successful when the students correctly choose which best reason to prevent cold stress. The neonate will stabilize its temperature by 8 hours after birth if kept warm and dry. It takes energy to keep warm, so the neonate has to remain in an extended position. If the neonate becomes cold stresses, it will eventually develop respiratory distress. Evaporative heat loss happens when the neonate is not bundled and does not have a hat on.
If the neonate becomes cold stresses, it will eventually develop respiratory distress.
A client comes to the emergency department with moderate vaginal bleeding. She says "I have had to change my pad about every 2 hours and it looks like I may have passed some tissue and clots" The woman reports that she is 9 weeks pregnant. Further assessment reveals the following: *Cervical dilation *Strong abdominal cramping *Ultrasound positive for products of conception The nurse suspects that the woman is experiencing which type of spontaneous abortion (miscarriage) Threatened Complete Incomplete Inevitable
Incomplete
A child is hospitalized with burns over 25% of the body. The nurse is preparing to perform a dressing change. What aspect of changing the childs dressings is most important for the nurse to consider? Pain management Activities for distraction Infection prevention Therapeutic communication
Infection prevention
A nurse is caring for a 2-year-old child with a complex medical history including preterm birth, hypoxic-ischemic encephalopathy, cerebral palsy, gastrostomy tube feeds, and epilepsy. This is the child's third admission in 1 month, due to increasing seizure activity. The care team and family are planning a tracheostomy for long-term ventilation. The nurse feels conflicted about the intervention and wishes the family would choose end-of-life care to reduce the childs suffering. How should the nurse proceed? Speak with the primary health care provider to request a second option about the plan of care Discuss these concerns with the client's family to advocate for end-of-life care measures Request the chaplain speak with the family to provide support and guidance in their decision-making Personally reflect on these feelings of conflict and distress related to the clients plan of care
Personally reflect on these feelings of conflict and distress related to the clients plan of care
A 17 year old women has become pregnant as her boyfriend refused to wear condoms. The boyfriend calls her names, often becomes jealous and although rare sometimes hits her. Which condition is this pregnant client most at risk of developing in this pregnancy? Select all that apply Placental abruption (abruptio placentae) Sexually transmitted infection Post-term pregnancy Preterm birth Small for gestational age infant
Placental abruption (abruptio placentae) Sexually transmitted infection Preterm birth Small for gestational age infant
A 6 year old child is playing. Which play scenarios witnessed by the nurse are indicative that the child is sexually abused? Select all that apply Playing with a boy and girl doll in a sexually graphic manner Arranging dolls in unnatural positions for play Stating that boys and girls love each other Using inappropriate adult language
Playing with a boy and girl doll in a sexually graphic manner Using inappropriate adult language
After the nurse teaches a local womans group about postpartum affective disorders, which statement by the group indicated that the teaching was successful? Postpartum psychosis usually involves psychotropic drugs but not hospitalization. Postpartum psychosis usually appears soon after the woman comes home. Postpartum depression develops gradually, appearing within the first 6 weeks. Postpartum blues usually resolves by the 4th or 5th postpartum day.
Postpartum depression develops gradually, appearing within the first 6 weeks.
The nurse is monitoring a client in labor who has had a previous birth via cesarean and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate and deep variable deceleration on the fetal monitor. The client reports severe pain in the abdomen and shoulder. What should the nurse prepare to do? Prepare the client for a cesarean birth. Turn the client on their left side. Bolus the client with another dose of medication through the eopidural. Place the client in the knee-chest position
Prepare the client for a cesarean birth.
Newborn born via ceasearn at 1840. ID band verified. Currently in warmer. Temperature: 96.7F (36C) Respiratory rate: 38 breaths/min. Heart rate: 142 beats/min. Pulse oximeter reading is 99% on room air. Assessment via flowsheet. Strong vigorous crying noted. Irritability noted with jitteriness. Warmed room temperature to increase newborn temperature. Cap on. Prepare to obtain the glucose level. Assess for patency of esophagus. Monitor bilirubin for decreasing levels. Provide humidified oxygen via blow-by
Prepare to obtain the glucose level.
A nurse admits a 10 year old with spina bifida who is confined to a wheelchair. When asking the parent and child questions, the parent appears disinterested and distant, allowing the child to answer all questions. What typical caregiver response is this parent displaying? Overprotection Denial Acceptance Rejection
Rejection
The postpartum nurse is providing care for a client who has just given birth and had epidural anesthesia. Her vital signs are stable, her pain is a 3 on a scale of 0 to 10, and she states that she is tired. The feeling in the clients' legs has returned, but she cannot lift her knees, and she has not been out of bed. What is the most appropriate nursing diagnosis to include in the plan of care at this time? Acute pain Activity Intolerance Risk for Injury Disturbed sleep pattern
Risk for Injury
The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis? Deficient knowledge related to cast care. Self-care deficit related to immobility Risk for impaired skin integrity due to cast and location Risk for delayed development related to immobility
Risk for impaired skin integrity due to cast and location
A 17 year old primigravida with type 1 diabetes is at 37 weeks gestation and comes to the clinic for an evaluation. The nurse notes her blood sugar has been poorly controlled and the health care provider is suspecting the fetus has macrosomia. The nurse predicts this step will be completed next: Scheduling a caesarean delivery at 39 weeks Allowing her to continue without plans for delivery Scheduling the women for induction of labor today Preparing for amniocenteses and fetal lung maturity assessment.
Scheduling a caesarean delivery at 39 weeks
The nursing instructor is teaching a group of student nurses about the current use of episiotomies during the labor process. The instructor determines the session is successful when the students correctly choose which situation that may require the health care provider to preform an episiotomy: Shoulder dystocia Persistent occiput anterior position Multifetal births VBAC delivery
Shoulder dystocia
The nurse is looking at the latest lab work for her postpartum client. The clients predelivery hemoglobin and hematocrit (H & H) were 12.8 and 39, respectively. This morning, the clients values are 8.9 and 30. How would the nurse interpret these lab values? These values are expected for a 1 day postpartum mother. The health care provider needs to be notified of the latest lab values. The client will be tired, so encourages her to sleep whenever the baby sleeps. The client will need a transfusion, so the RN needs to be notified.
The health care provider needs to be notified of the latest lab values.
The public health nurse is discussing immunizations with a group of caregivers of infants. One of the mothers ask the nurse why the child will need immunizations. Which statement would be the most appropriate for the nurse to make to this mother. The antibodies the fetus gets from the mother are in the placenta, so after birth they are no longer available to the infant. Infants are unable to develop antibodies to protect them from diseases so they must be immunized. The infant is born with immunity to some diseases, but those immunities decrease over the first year of life. The immunities that the infant is born with are not for the same diseases they will be immunized against.
The infant is born with immunity to some diseases, but those immunities decrease over the first year of life.
While assisting a registered nurse (RN) in the admission of a child to the pediatric unit, the licensed practical nurse (LPN) hears the RN state the following statements about the unit. Which statement will the LPN ask the RN to clarify? We do our best to include foods you like on each meal tray. We will involve your caregiver in as much of your care as we can. We encourage your caregiver to visit as much as they can. We try to assign different nurses each shift so you get to know everyone.
We try to assign different nurses each shift so you get to know everyone.
Myopia (nearsightedness)
a condition resulting from a refractive error in which light rays entering the eye are brought into focus in front of the retina.
External Fixation
a fracture treatment procedure in which pins are placed through the soft tissues and bone so that an external appliance can be used to hold the pieces of bone firmly in place during healing. **Special skin care at pin sites necessary *Leave OTA & inspected q8h, *Teach family caregivers and child proper care *May be in place for up to a year *Recognize s/s of infection at pin sites **Clothes WILL NOT COVER UP-Upsetting to the child
Iron-Deficiency Anemia
anemia caused by inadequate iron intake Treatment: *Diet & nutrition information as needed *Encourage fresh raw fruit, hydration to avoid constipation *Drink prepared medication in juice with a straw to avoid staining teeth *Good oral care *Orange juice helps body absorb iron *Milk interferes with absorption
Acute Leukemia
appears suddenly, progresses rapidly, majority of children leukemias. Treatment: CNS prevention therapy-methotrexate
Impetigo
bacterial skin infection characterized by isolated pustules that become crusted and rupture Treatment: *Finish entire antibiotic regimen *May need IV antibiotics-ask about allergies is priority
Osteomyelitis
infection of the bone Diagnosis: *Positive blood cultures ***Obtain before initiating antibiotics Treatment: **IV up to 2 weeks, then oral antibiotic therapy up to 4 weeks
Acne Vulgaris
inflammation of the skin follicles Clinical manifestations: Appearance of comedones, papules, and pustules on face, back and chest
Plumbism (Lead Poising)
lead poisoning Treatment: *Chelating agent to remove lead *Follow-up: routine examination to prevent recurrence and observe for any residual brain damage *Teach to report any new or unusual s/s to HCP Prevention: *Fully flush faucets before using for cooking, drinking or making formula *Boil well water, use bottled water *Make sure child eats regular meals *Encourage child to eat foods high in iron and calcium *Encourage hydration
Nephrotic Syndrome
loss of large amounts of plasma protein, usually albumin, through urine due to an increased permeability of the glomerular membrane Assessment: *•May appear "chubby" which is misleading •Loss of appetite, fatigue, irritability, malnutrition Diagnosis: •Urine: marked proteinuria, hematuria usually not present •Blood: hyperlipidemia, low blood serum protein & albumin levels
Dysmenorrhea
painful menstruation (cramps) *Primary: part of normal cycle without associated pelvic disease ***Secondary: result of pelvic pathologic changes, PID, fibroids, endometriosis
Hydrocele
sac of clear fluid in the scrotum •The processes closes soon after birth; if the processes does not close, fluid from the peritoneal cavity passes through, causing hydrocele ***(not associated with infertility) **Typically resolves on its own (wait and see) •If hydrocele remains by end of first year, corrective surgery is performed
Intussusception
telescoping of the intestines Signs and Symptoms: *Stools: sausage-shaped mass palpated through upper mid/R abdominal wall * Cardinal symptoms: shock, vomiting, "current jelly" stools (blood & mucous)
A 20-year old pregnant client is positive for hemoglobin S. The nurse explains to the client that she will need to perform which actions during her pregnancy? Select all that apply Drink lots of fluids Avoid conditions of low oxygen tension, such as high altitudes Eat high protein meals. Be on bed rest
Drink lots of fluids Avoid conditions of low oxygen tension, such as high altitudes
After teaching a group of nursing students about factors affecting growth and development, the instructor determines that the teaching was successful when the group identifies which of the following as a biological factor that has influenced on growth and development? Genetics Poor Diet Sensory stimulation illicit drugs
Genetics
A nurse is preparing a teaching plan for a new mother who will be using a formula to feed her newborn. Which instructions would the nurse prioritize in the teaching? Select all that apply Use a pillow if propping the bottle to feed Interact with the infant during the feeding sessions Hold the infant semi-upright and close to promote eye contact. Tilt the bottle so that the nipple fills with formula Wash hands thoroughly after each feeding session
Interact with the infant during the feeding sessions Hold the infant semi-upright and close to promote eye contact. Tilt the bottle so that the nipple fills with formula
A 2 year-old with pneumonia has recently been hospitalized. When the lunch tray arrives on the floor, the nurse caring for the client sets up the tray and allows the child to self-feed with a spoon despite the mess. What is the nurses best reason for these actions? To foster autonomy To foster industry To foster initiative To foster trust
To foster autonomy
A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching? He'll need antibiotics for a bit after the surgery to prevent infections. We can give him a pacifier to help satisfy his need to suck. The head of his bed will be elevated to prevent him from aspirating. We can probably start feeding him with the bottle about a day after the surgery.
We can probably start feeding him with the bottle about a day after the surgery.
Hyperopia (farsightedness)
a refractive error in which light rays entering the eye are focused behind the retina.
Gastroesophageal Reflux Disease (GERD)
backflow of contents of the stomach into the esophagus, often resulting from abnormal function of the lower esophageal sphincter, causing burning pain in the esophagus Nursing Care: *Thickened feedings/formula with rice cereal, small/frequent feedings, positioning, burp frequently *Monitor I&O, daily weight, emesis, respiratory distress *Skin care *Teaching family caregivers-side or back position for sleep
Otitis Media
inflammation of the middle ear Otoscopic exam shows bright red, bulging eardrum Spontaneous rupture may occur followed by purulent drainage and relieved pain
The nurse is caring for a child who weighs 77 lb. The medication ordered for the child has a therapeutic dosage range of 33mg/kg per day to 48 mg/kg per day. The medication ordered is to be given 4 times per day. Which dosage would be appropriate for the nurse to administer to this child in one dose? 375 mg per dose 40.8 mg per dose 250 mg per dose 28 mg per dose
375 mg per dose
The client in active labor at 5 cm dilation has a prescription for 0.5 mg/kg of fentanyl IV push every 15 minutes for the pain to a maximum of 100 mg. The client weighs 155 lb (70.45kg). The fentanyl is provided in a 100 mg/2mL ampule, to be reconstituted with 8 mL saline for a total reconstituted. volume of 10 mL in total. What volume of reconstituted fentanyl should the nurse administer per dose? Record your answer in (mL) rounded to the nearest tenth. 5 2 0.7 3.5
?
The nurse is caring for a group of children in the pediatric unit. The nurse should collect further data and explore the possibility of child abuse (child mistreatment) in which situation: A 9 year old with a compound fracture of the tibia, which the caregiver reports as having been caused when the child attempted a flip on a skateboard. A 10 year old with a simple fraction of the femur, which the caregiver reports as having been caused when the child fell down a set of stairs. A 6 year old with a greenstick fracture of the wrist which the caregiver reports as having been caused when the chilf fell while ice-skating. A 7 year old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a little league player.
A 7 year old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a little league player.
Diarrhea and gastroenteritis
A disturbance in intestinal motility characterized by an increase in frequency, fluid content, and volume of stools Signs & Symptoms: *Moderate sign: sunken fontanels *Severe: dusky extremities, skin tenting, hypotention
Hemophilia
A hereditary disease where blood does not coagulate to stop bleeding Assessment & Diagnosis: *Bruises easily, minor lacerations may bleed heavily, tooth extractions *Monitor aPTT (activated partial thromboplastin clotting time) Safety is paramount: protect from injury when hospitalized
Upon assessing the newborns respirations, which finding would cause the nurse to notify, the primary care provider? Short period of apnea that last 10 seconds in a pink newborn Coughing and sneezing in the newborn A respiratory rate of 15 breaths per minute with nasal flaring A respiratory rate of 45 breaths per minute with acrocyanosis
A respiratory rate of 15 breaths per minute with nasal flaring
The nurse is educating a class of high school students on safe sexual practices. The nurse knows the group understood the content when a group member makes which statement? A condom is the best way to prevent pregnancy Spermicide should be applied immediately following intercourse Abstinence is the only way to prevent the spread of sexually transmitted infections A diaphragm can be used by males and females
Abstinence is the only way to prevent the spread of sexually transmitted infections
Epiglottitis
Acute inflammation of epiglottis resulting in blockage of airway *requires immediate attention-high risk for respiratory distress
A nurse is assessing a postpartum client. Which finding causes the nurse the greatest concern? Leg pain on ambulation with mild ankle edema. Calf pain with dorsiflexion of the foot Acute onset of sharp, stabbing chest pain with shortness of breath Perineal pain with swelling along the episiotomy
Acute onset of sharp, stabbing chest pain with shortness of breath
An 18 year old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion (elective termination of pregnancy) but her cultural background forbids it. She is very unhappy about being regnant and even expresses a wish for a miscarriage. Which action by the nurse is most appropriate? Continue to monitor the clients hyperemesis gravidarum. Share the information with the clients family. Encourage the client to be positive about the situation. Contact the health care provider to report the clients feelings.
Contact the health care provider to report the clients feelings.
Appendicitis
Dangerous infection of the appendix Clinical manifestation: In young children may be difficult to evaluate, general symptoms uncommon, appendix may already be ruptured when discovered. ***Appendix wall is thin, ruptures easily.
Acute Postreptococcal Glomerulonephritis
Degenerative inflammation of the Glomeruli in the Nephron of the Kidneys Nursing Care: •Bed rest, contact precautions, when allowed out of bed must not become fatigued, I&O, intake restrictions based on output, monitor blood pressure, **urine dipstick tests for protein and blood; if condition persists for more than 1 year, probably chronic condition
The nurse is caring for a client recently diagnosed with Down syndrome. The client is not able to complete self-care and requires assistance with all activities of daily living. Which is a priority for the nurse? Monitor the clients ability to perform self-care over time Ensure the family has access to a counselor to share feelings as needed Develop a long-term plan of care for the client based on family goals Determine the familys needs and the familys ability to care for the client
Determine the familys needs and the familys ability to care for the client
The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply Do not remove the identification bands until the newborn is discharged from the hospital. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Don't leave the newborn unattended unless the mother is going to the bathroom. Know when the newborn is scheduled for any tests and how long the procedure will last.
Do not remove the identification bands until the newborn is discharged from the hospital. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Know when the newborn is scheduled for any tests and how long the procedure will last.
Which action is a priority when caring for a client during the fourth stage of labor? Encouraging the client to void Assisting with perineal care Assessing the uterine fundus Offering fluids as indicated
Assessing the uterine fundus
A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpitates the client's fundus. Which finding would the nurse identify as expected? At the level of the umbilicus Two fingerbreadths above the umbilicus Two fingerbreadths below the umbilicus Four fingerbreadths below the umbilicus
At the level of the umbilicus
A nurse notes a womans pre-labor vitals signs were: temperature 98.8 F (37.1 C) blood pressure 120/70 mm Hg: Heart rate 80 beats/min and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize? BP 90/50 mm Hg. heart rate 120 bpm, respirations 24 breaths/min Shaking chills with a fever of 99 F (37.2C) Heart rate 70 bpm and excessive, soaking diaphoresis Blood loss of 250 mL and WBC 25,000 cells/mL
BP 90/50 mm Hg. heart rate 120 bpm, respirations 24 breaths/min
A 3 year old child is admitted to the hospital with osteomyelitis of the right femur. Which laboratory test should the nurse obtain first before starting an IV antibiotic? Hematocrit Platelets White blood cell count Blood culture & sensitivity
Blood culture & sensitivity
A new mother calls for the nurse to come to her room while she is breastfeeding her newborn. She reports that the baby will not wake up and latch on. What can the nurse do to assist this mother in getting her newborn to nurse? Have the mother lie down on her back and place the newborn onto the breast. Vigorously pat the newborns bottom to ensure he is awake. Remove the Mothers gown and lay the infant on the breast. Change the diaper and gently rub the newborns back
Change the diaper and gently rub the newborns back
Chapter 35
Chapter 35
Chapter 36
Chapter 36
Chapter 37
Chapter 37
Chapter 38
Chapter 38
Chapter 39
Chapter 39
Chapter 40
Chapter 40
Chapter 41
Chapter 41
Which nursing consideration is most important when communicating with pediatric clients at the end of life? Length of illness Childs developmental level Terminal diagnosis Parental acceptance of diagnosis
Childs developmental level
The licensed practical nurse (LPN) and registered nurse (RN) are caring for a 4-year-old client diagnosed with gastroenteritis with vomiting and diarrhea. On admission, the clients vital signs were: *Pulse, 70 beats/minute *Resiratory rate, 26 breaths/minute *Blood pressure, 76/38 mm Hg *Axillary temperature, 101.4F (38.5C) The RN tells the LPN to obtain a rectal temperature on the client. Which action by the LPN is appropriate? Notify the clients primary health care provider of the RN's statement. Determine if the client has had a rectal temperature taken before. Clarify with the RN the appropriate location to obtain the clients temperature. Gather supplies and obtain a rectal temperature from the client.
Clarify with the RN the appropriate location to obtain the clients temperature.
A pregnant woman comes to the birthing center, stating she is in labor and does not know how far along her pregnancy is because she has not had prenatal care. A primary care provider performs an ultrasound that indicates oligohydramnios. When the clients membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this client? Complications of preterm labor. Complications of a post-term pregnancy Complications of placenta previa Abruption placentae
Complications of a post-term pregnancy
Food Allergies
An immune system response to a food that the body perceives as harmful Common foods: Eggs, Milk, Wheat, Corn, Legumes (Peanuts, Soybeans), Oranges, Strawberries, Chocolate
Menstrual Disorders/Mittelschmerz
Mittelschmerz: dull, aching abdominal pain at time of ovulation, relieved by analgesics, heating pad, warm bath.
Kawasaki Disease
(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. Treatment: IV immunoglobulin (IVIG) therapy *Relieve symptoms, prevent coronary artery abnormalities. Asprin: *Relieve inflammation, fever *Up to 1 year as an antiplatelet
The health care provider prescribes 50 mg daily by mouth of clomiphene for a client having fertility problems. The client cannot swallow pills. Available is 200mg/5 ml elixir. How many milliliters of the medication would the nurse administer? Record your answer to the nearest hundredth. 1.50 mL 1.25 mL 20 mL 1.30 mL
1.25 mL
4 mL fluid x % of body burned x weight in kilograms = total amount of fluid over 24 hours Give half of the fluid over the first 8 hours Give remaining fluid over the next 16 hours A nurse is providing care for a child who requires intravenous fluid replacement. The child has burns over 32% of the body and weighs 40 lb (18.1 kg) Using the above formula, how much fluid should the nurse administer over the first 8 hours? Record your answer to the nearest tenth 23.2 mL 2316.8 mL 11.6 mL 1158.4 mL
1158.4 mL
Acute Rheumatic Fever (ARF)
An autoimmune sequela of streptococcal infection; results from cross-reactivity of antibodies produced against certain streptococcal M protein epitopes with epitopes of the heart, joints, and nervous system. *Treatment: prevention & treatment of residual heart disease *Restricted activities (may require bedrest), low sodium diet
A nursing student is learning how to insert and administer enteral feedings through a nasogastric (NG) tube. The student identifies the best way to check placement before each feeding as which of the following? Aspirating stomach contents and checking pH It is not necessary to check placement each time Obtaining an x-ray Inserting air into the tube and listening for sounds in the stomach
Aspirating stomach contents and checking pH
A nurse is caring for a newborn client diagnosed with spina bifida. Which assessment finding would be a priority for the nurse who is monitoring for the risk of hydrocephalus? Assess the newborn's neurological response. Assess the motor function of the lower extremities. Assess head circumference measurements. Assess the newborns weight.
Assess head circumference measurements.
Fractures: Traction
Application of pulling force to an injured or disease body part or cavity. ***Pin site care vitally important if have skeletal traction; high risk for infection
A new mother states her breast are hard, swollen, and painful. Which interventions will the nurse suggest to this client? Select all that apply Apply cold packs to each breast Massage the breast Prior to feeding, apply moist heat to the breast Ask the health care provider for an opiod Feed the infant more often
Massage the breast. Prior to feeding, apply moist heat to the breast. Feed the infant more often.
The nurse collects a history of a newly pregnant woman. Which data does the nurse identify in the health history that places this client at risk for having an infant with a chromosomal anomaly? G8P7 Sister with down syndrome Developed gestational diabetes in last pregnancy. Third child born at 28 weeks gestation Maternal age 37 years
Maternal age 37 years Sister with down syndrome
Acute bronchiolitis (acute interstitial pneumonia)
Most common during first 6 moths *caused by viral infection, in most cases RSV (respiratory syncytial virus) Treatment & nursing care: *Supportive care in hospital *Nasal suctioning, rest, increased fluids, humidified oxygen, monitoring of oxygen, 02 sat monitoring *Antibiotics not given if found to be viral infection *IV fluids *Contact and droplet transmission precautions *Antiviral drug as inhalant: ribavirin, but only in very specific cases *Bronchodilators have been found to not be helpful in most cases
In which areas would bruising on a young toddler alert the nurse to a potential abuse situation? Select all that apply Forehead Bony prominences Mouth Thighs Abdomen
Mouth Thighs Abdomen
Respiratory System
Newborns cannot breathe through their mouth when first born. It is a learned action, so it is essential to keep nasal passages clear. *It takes about 4 weeks for them to breathe through their mouth *Exception is when they are crying
The nurse is caring for a prenatal client in the clinic. The client states, I wish I did not have to go through the pain of labor and a vaginal birth and could just schedule a cesarean birth instead "What is an approriate response (by the nurse? Select all that apply Lets talk with your health care provider about an appropriate time to schedule the cesarean birth. Newborns who are born following the laboring process have better respiratory adaptation. Newborns who are born vaginally have less suctioning after birth. A vaginal birth is healthier emotionally for you because your hormones regulate better than after a cesarean birth.
Newborns who are born following the laboring process have better respiratory adaptation. Newborns who are born vaginally have less suctioning after birth.
The nurse obtains vital signs on a 7 year old client diagnosed with a urinary track infection (UTI). The clients heart rate is 126 beats/minute, tympanic temperature 102F (38.8C), and blood pressure 90/50 mm Hg. Which action will the nurse take next? Document the findings in the clients medical record. Repeat the vital signs in 15 minutes. Notify the primary health care provider. Obtain the clients rectal temperature.
Notify the primary health care provider.
While working in the emergency room, the nurse receives a call that a 3-year old child sustained extensive burns in a house fire. Assuming all of the following actions are included in the standing burn care protocol, which action should be the nurse perform first? Give a tetanus toxoid injection insert a nasogastric tube to empty the stomach Obtain a weight Ask the child to drink a glass of milk
Obtain a weight
Immune Thrombocytopenia
Occurs in children 2/6 yo. Pathogenesis involves antibodies that bind to platelets and subsequent destruction of these complexes in spleen. Its preceded with viral infection, and presents with petechia, purpura, hematuria, or GI bleeding. No adenopathy Treatment and Nursing care: *protect from falls & trauma *toys have to have soft corners *Soft toothbrush *avoid adhesive tape to skin *Pad crib rails to prevent bruising *No rough paly
The nurse is monitoring a client at 41 weeks gestation receiving IV oxytocin. Which action should the nurse prioritize if noticeable contractions are occuring every 2 minutes, lasting 60 to 90 seconds on the fetal monitor? Change the clients position Stop the IV oxytocin infusion Notify the health care provider Administer oxygen 10L via face mask
Stop the IV oxytocin infusion
Fractures: Casts
•Monitor for compartment syndrome: serious neurovascular concern, must be reported and addressed immediately •Notify HCP, ice first and then assess Assessment: •CMS (circulation, movement, sensation) checks; includes observing, documenting, reporting 5 Ps •Pain: any sign, exact location •Pulse: check related locations for injured extremity •Paralysis: check hand or foot function •Pallor: check nailbeds of fingers or toes, capillary refill •Paleness: discoloration, coldness Family Teaching: *Risk for impaired skin integrity
Enterobiasis (Intestinal Parasites)
•Pinworm infection •Invades cecum; articles contaminated with pinworm eggs spread pinworms; child ingests pinworm eggs, grow and mature in cecum, when adult female ready to lay eggs, crawls out anus and lays eggs on perineum •Child scratches itching perineum, collects eggs under fingernails, causing reinfection and/or spread to others via clothing, bedding, food, toilet seats •Eggs can also float in air and be inhaled •Life cycle about 6 to 8 weeks Nursing Care: *Encourage all family members to be treated, may be infected and not know it.
Amenorrhea
•Primary: no previous menstruation •After age 16 needs diagnostic survey for genetic abnormalities, tumors, or other problems •Secondary: missing 3 or more periods after menarche •Discontinuing contraceptives, sign of pregnancy, physical or emotional stressors, underlying medical condition
Vaginitis/Trichomonas STI
•Yellow, green malodorous discharge and dysuria
Hearing Impairment: Clinical Manifestations
◦May have difficulty with normal conversation, especially if not looking at an individual talking ◦Mild to moderate hearing loss may go undetected ◦May be gradual ◦Certain reactions and mannerism common may be perceived as "poor behavior" ◦Locate a sound and turn head to one side when listening ◦Fails to comprehend when spoken to, gives inappropriate answers to questions ◦Consistently turns up volume on television or radio ◦Cannot whisper or talk softly
