Prep U from Ricci

A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority? A. Grieving related to the loss of "a healthy full-term newborn" B. Ineffective thermoregulation related to decreased amount of subcutaneous fat C. Risk for injury related to the very thin epidermis layer of skin D. Imbalanced nutrition: Less than body requirements related to the premature digestive system

B. Ineffective thermoregulation related to decreased amount of subcutaneous fat

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process? A. bluish skin discoloration B. listlessness or lethargy C. stained umbilical cord and skin D. meconium stained fluids followed by tachypnea

D. meconium stained fluids followed by tachypnea

To help prevent obesity, which intervention would the nurse include in an adolescent's plan of care? A. Plan a diet of 3,000 calories per day. B. Encourage sources of proteins with fat. C. Describe a normal serving size. D. Plan a diet of 1,500 calories per day.

C. Describe a normal serving size.

By what age should the child know his/her own gender? A. 3 years B. 1 year C. 4 years D. 2 years

A. 3 years

The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best? A. Continue to monitor the progress of labor. B. Auscultate fetal heart rate (FHR) in the left upper quadrant. C. Prepare the client for cesarean birth of the fetus. D. Educate the client this fetal position may result in a longer labor.

A. Continue to monitor the progress of labor.

A group of 10-year-old girls have formed a "girls only" club. It is only open to girls who still like to play with dolls. How should this behavior be interpreted? A. encouragement for bullying and sexism B. immaturity for this age group C. appropriate social development D. poor peer relationships

C. appropriate social development

The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor? A. active B. stage two C. latent D. stage three

C. latent

A mother states that her 6-year-old has starting biting nails and regressing to baby talk since beginning school. What instructions are best for the nurse to give the mother regarding this behavior? A. Get a description of the classroom behavior from the teacher. B. Make time each day to spend with the child individually. C. Remind the child to stop each time the behavior is witnessed. D. Apply a nail biting product to the nails to deter biting.

B. Make time each day to spend with the child individually.

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? A. diffuse abdominal cramping B. rupturing of fetal membranes C. start of regular contractions D. dilation (dilatation) of cervix diameter to 10 cm

D. dilation (dilatation) of cervix diameter to 10 cm

The nurse is conducting a well-child assessment of a 4-year-old. Which assessment finding warrants further investigation? A. presence of 19 deciduous teeth B. presence of 20 deciduous teeth C. presence of 10 deciduous teeth D. absence of dental caries

C. presence of 10 deciduous teeth

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? A. gaze aversion B.. hiccups C. quiet, alert state D. yawning

C. quiet, alert state

A perinatal nurse is working as a member of a local community health task force to address the impact of substance use during pregnancy. The group is to come up with recommendations for programs that will have a positive impact. After reviewing current research on the topic, on which area(s) will the group likely focus? A. alcohol B. methamphetamines C. marijuana D. heroin E. cocaine

A. alcohol D. heroin E. cocaine

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best? A. "The analgesia will limit your ability to be out of bed without assistance." B. "The analgesia will block pain sensation and limit your ability to push." C. "The analgesia will reduce the sensation of pain for a limited period of time." D. "The analgesia will allow for a pain-free birth experience."

C. "The analgesia will reduce the sensation of pain for a limited period of time."

The parents of a school-aged child with school refusal have received professional guidance by the school psychologist, pediatrician, and three different psychiatrists. Based on this, which nursing diagnosis would be most appropriate? A. Ineffective tissue perfusion, cerebral, related to anxiety over attending school B. Noncompliance with expected school behavior related to school phobia C. Disturbed thought processes related to delusional behavior D. Compromised parental coping related to inability to assist with school fears

D. Compromised parental coping related to inability to assist with school fears

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? A. The father's coaching role may be disrupted at times. B. The infant may show increased drowsiness. C. The mother may have continued memory loss postpartum. D. The mother may have difficulty working effectively with contractions.

D. The mother may have difficulty working effectively with contractions.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? A. shoulders B. occiput C. brow D. buttocks

B. occiput

A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement? A. "All congenital disorders can be diagnosed at birth." B. "Congenital defects may be caused by genetic or environmental factors." C. "Hydrocephalus may be recognized at birth." D. "Hydrocephalus may not be diagnosed until after a few weeks or months of life."

A. "All congenital disorders can be diagnosed at birth."

A nurse is teaching a group of parents of preschoolers about safety. Which information would the nurse include? Select all that apply. A. "Do not allow your child to approach strange dogs." B. "Role-model bicycle safety by wearing a helmet too." C. "Allow your child to ride in the front seat of the car." D. "Do not refer to medicines as candy." E. "Have your child hold hands with a grown-up in parking lots."

A. "Do not allow your child to approach strange dogs." B. "Role-model bicycle safety by wearing a helmet too." D. "Do not refer to medicines as candy." E. "Have your child hold hands with a grown-up in parking lots."

During a health history assessment, the mother of a 10-year-old girl tells you that her daughter does not have time to "play" because she is busy going to gymnastics, cheerleading, art class, flute lessons, reading club, and soccer. What should the nurse's response be? A. "Play helps children to develop cognitively, socially, physically, and emotionally." B. "All of these other activities teach you as much as traditional play." C. "Wow, that is a lot of stuff for a girl her age." D. "It is understandable not playing any more with all these other activities."

A. "Play helps children to develop cognitively, socially, physically, and emotionally."

A chronically ill adolescent is readmitted to the hospital with an infected wound requiring long-term dressing changes. What is the best way the nurse can encourage independence for this client? A. Allow the adolescent to choose the time for the dressing change. B. Teach the parents to perform dressing changes at home. C. Have the school provide homework. D. Have the adolescent go to the teen room every day.

A. Allow the adolescent to choose the time for the dressing change.

A newborn with high serum bilirubin is receiving phototherapy. Which is the most appropriate nursing intervention for this client? A. Application of eye dressings to the infant B. Placing light 6 inches above the newborn's bassinet C. Delay of feeding until bilirubin levels are normal D. Gentle shaking of the baby

A. Application of eye dressings to the infant

The nurse caring for a newborn notes a distended abdomen approximately 24 hours after birth. Which action should the nurse take after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement? A. Inform the health care provider immediately. B. Attempt to take a rectal temperature. C. Inform the parents that the newborn might need surgery. D. Schedule radiography to diagnose the problem.

A. Inform the health care provider immediately.

Which nursing measure is most effective in reducing newborn infections? A. Maintain medical asepsis while providing care. B. Promote early discharge of all newborns. C. Place newborns in an isolette. D. Limit the number of newborns in newborn nurseries.

A. Maintain medical asepsis while providing care.

At birth, a neonate is diagnosed with brachial plexus palsy. The parent asks how the nurse knows the neonate's positioning of the arm is a result of the palsy and not just a preferred position. The nurse would show the parent that the neonate has asymmetry of which neonatal reflex? A. Moro B. stepping C. rooting D/ Babinski

A. Moro

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? A. Oxytocin B. Magnesium sulfate C. Domperidone D. Calcium gluconate

A. Oxytocin

The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client? A. deep venous thrombosis B. uterine atony C. postpartum hemorrhage D. metritis

A. deep venous thrombosis

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which primary conditions? Select all that apply. A. placental abruption (abruptio placentae) B. severe preeclampsia C. septicemia D. isoimmunization E. ectopic pregnancy

A. placental abruption (abruptio placentae) B. severe preeclampsia C. septicemia

The nurse determines a newborn is small-for-gestational-age based on which characteristics? A. wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores B. wasted appearance of extremities, gelatinous umbilical cord, and abundant subcutaneous fat stores C. reduced subcutaneous fat stores to buttocks, thicker umbilical cord, and smaller head compared to body D. normal subcutaneous fat stores, cord-like umbilical cord, and increased development to extremities

A. wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores

An infant born 10 minutes prior was brought into the nursery for an examination. The nurse notices the infant's lip and palate are malformed. The parent comes up to door and asks if the infant seems okay. What is the appropriate response by the nurse? A. "Oh yeah, the infant seems fine, you can see your infant soon." B. "Come on over and I will explain your infant's exam and findings." C. "Wait outside and we will call you later." D. "The infant is okay, just wait until your health care provider speaks to you."

B. "Come on over and I will explain your infant's exam and findings."

The nurse is counseling an overweight, sedentary 15-year-old girl. The nurse is assisting her to make appropriate menu choices. Which statement indicates the adolescent understands how to make appropriate dietary selections? A. "Because of my age, my dairy intake is unlimited." B. "I need to eat plenty of fruit each day." C. "I avoid all fat intake." D. "To lose weight my protein intake should be limited to 2 to 4 servings per day."

B. "I need to eat plenty of fruit each day."

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? A. "If you don't attempt to void, I'll need to catheterize you." B. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." C. "I'll contact your health care provider." D. "I'll check on you in a few hours."

B. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

The parent of a 4-year-old child tells the nurse about being frustrated because all the parent seems to do lately is fight with the child over what the child wants to eat and wear. The parent notes sometimes wanting to spank the child for always disagreeing. What would be the best suggestion for the nurse to make to this parent? A. "Take some toys away when the child acts like that." B. "Use the time-out technique for discipline." C. "It is not normal to feel that way." D. "Spank lightly to get the child's attention."

B. "Use the time-out technique for discipline."

The father of a 2-year-old girl tells the nurse that he and his wife would like to begin toilet training their daughter soon. He asks when the right time is to begin this process. What should the nurse say in response? A. "The best time to start toilet training is as soon as the child begins walking." B. "When she starts tugging on a wet or dirty diaper, she is letting you know she's ready." C. "She's well past the age to begin toilet training; most children are ready by age 1, when they have developed the needed nervous system control." D. "It is best to wait a little longer, until she is 3; only then will she be socially developed enough to understand what you are asking her to do."

B. "When she starts tugging on a wet or dirty diaper, she is letting you know she's ready."

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor? A. Monitor vital signs. B. Assess the amount of cervical dilation (dilatation). C. Obtain urine specimen for urinalysis. D. Monitor hydration status.

B. Assess the amount of cervical dilation (dilatation).

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? A. Bloody fluid B. Clear to straw-colored fluid C. Greenish fluid D. Cloudy white fluid

B. Clear to straw-colored fluid

Which protective equipment is most appropriate when assisting the health care provider in the delivery of the fetus? Select all that apply. A. Hair net B. Goggles C. Gloves D. Gown E. Face mask

B. Goggles C. Gloves D. Gown

The nurse is supervising a play group of children on the unit. The nurse expects the toddlers will most likely be involved in which activity? A. Pretending to be mommies and daddies in the play house B. Playing with the plastic vacuum cleaner and pushing it around the room C. Watching a movie with other children their age D. Painting pictures in the art corner of the room

B. Playing with the plastic vacuum cleaner and pushing it around the room

The nurse is caring for a preschool-age child in the hospital with severe developmental delays. The parents have three other younger children at home and both parents work full-time outside the home. The family has just moved to this area. Which nursing diagnosis would be the highest priority in regard to the parents at this time? A. Interrupted family processes B. Risk for caregiver role strain C. Readiness for enhanced parenting D. Imbalanced nutrition, less than body requirements

B. Risk for caregiver role strain

A nurse from the neonatal intensive care unit is called to the birth room for an infant requiring resuscitation. After placing the newborn in the sniffing position what would the nurse do next? A. Ventilate at a rate of 40 to 60 breaths per minute. B. Suction the mouth then the nose. C. Suction the nose then the mouth. D. Give 3 compressions with 1 breath every 3 seconds

B. Suction the mouth then the nose.

A 16-year-old client has been hospitalized 100 miles from home for 1 week to repair a fractured patella suffered in a skateboarding accident. She was cheerful and chatty when she first arrived, but the nurse notes in recent days she has become increasingly quiet and seems lonely. Which nursing intervention should the nurse prioritize for this client? A. Suggest that she read books and magazines from the hospital bookmobile. B. Take her to the teen lounge so she can meet and interact with other teens. C. Ask her caregivers to bring her siblings and friends to visit. D. Call the hospital's mental health unit to see if she can get some counseling.

B. Take her to the teen lounge so she can meet and interact with other teens.

A nurse is concerned that a 1-day-old newborn is becoming ill and may be septic. What sign of distress would validate the nurse's concerns? A. Respiratory rate of 40 breaths/min B. Temperature instability C. Heart rate of 152 beats/min D. Erythema toxicum

B. Temperature instability

A newborn is suspected of having gastroschisis at birth. How would the nurse differentiate this problem from other congenital defects? A. The umbilical cord comes out of middle of the defect. B. The intestines appear reddened and swollen and have no sac around them. C. The skin over the abdomen is wrinkled and looks like a prune. D. The abdominal contents are contained within a thin, transparent sac.

B. The intestines appear reddened and swollen and have no sac around them.

Which measurement best describes postpartum hemorrhage? A. blood loss of 400 ml, occurring at least 24 hours after birth B. blood loss of 1,000 ml, occurring at least 24 hours after birth C. blood loss of 800 ml, occurring at least 24 hours after birth D. blood loss of 600 ml, occurring at least 24 hours after birth

B. blood loss of 1,000 ml, occurring at least 24 hours after birth

The adolescent comes to the clinic seeking information about sexuality concerns. The clinic nurse assures the adolescent that confidentiality and privacy will be maintained unless a life-threatening situation occurs. Maintaining confidentiality demonstrates which nursing goal? Select all that apply. A. inappropriate response because adolescents are minors B. development of a trusting relationship C. compliance with existing laws D. an environment where adolescents can be truthful E. concern from parents who pay the office visit bill

B. development of a trusting relationship C. compliance with existing laws D. an environment where adolescents can be truthful

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred? A. flexion B. engagement C. extension D. expulsion

B. engagement

The nurse is caring for a pregnant woman who is struggling with controlling gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus? A. have a serious birth defect B. grow to an unusually large size C. suffer from symmetrical intrauterine growth restriction D. suffer from asymmetrical intrauterine growth restriction

B. grow to an unusually large size

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding? A. She feels like eating all the time. B. lack of pleasure C. She is over her interest in her baby. D. extreme periods of elation

B. lack of pleasure

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? A. variable decelerations B. prolonged decelerations C. early decelerations D. accelerations

B. prolonged decelerations

What medication does the nurse anticipate administering to the preterm newborn as an inhalant to improve the lungs' ability to mature? A. Rho(D) immune globulin B. surfactant C. neomycin D. heparin

B. surfactant

The parent of a 2-year-old client states it is the child's naptime. The child is refusing to take a nap and cries, "I have to put my babies to sleep first!" The parent states, "I am so sorry, I do not know what is wrong. My child does not act this way at home. My child has 2 baby dolls we rock to sleep each day at home before nap." Which response by the nurse is most appropriate? A. "Your child's behavior indicates discipline occurring at home is not consistent." B. "You need to have someone bring the baby dolls to the hospital." C. "A 2-year-old child's behavior can be greatly altered if rituals are not maintained." D. "I am sure your child is just acting out since your child is in the hospital and not at home."

C. "A 2-year-old child's behavior can be greatly altered if rituals are not maintained."

The mother of a 7-year-old girl is asking the nurse's advice about getting her daughter a 2-wheel bike. Which response by the nurse is most important? A. "Teach her where she'll land on the grass if she falls." B. "She won't need a helmet if she has training wheels." C. "Be sure to get the proper size bike." D. "Learning to ride the bike will improve her coordination."

C. "Be sure to get the proper size bike."

A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: A. "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." B. "It is flat and narrow, making it extremely difficult for the neonate to pass through." C. "It is rounded in shape and allows ample room for the neonate to fit through the passageway." D. "It is elongated, the width is roomy, but the length is narrow."

C. "It is rounded in shape and allows ample room for the neonate to fit through the passageway."

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? A. 100 mg/100 ml whole blood B. 80 mg/100 ml whole blood C. 45 mg/100 ml whole blood D. 30 mg/100 ml whole blood

C. 45 mg/100 ml whole blood

The nurse at an elementary school is explaining the concept of industry versus inferiority to a group of nursing students. What is part of this stage of Erikson's theory? A. The principle of conservation B. The conventional stage of development C. A sense of competence, mastery, and worth D. Lack of the ability to think abstractly

C. A sense of competence, mastery, and worth

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply. A. Handle the newborn as much as possible. B. Give the newborn a warm bath immediately. C. Dress the newborn in ways to preserve warmth. D. Take the newborn's temperature often. E. Supply oxygen for the newborn, if necessary. F. Discourage contact with parents to maintain asepsis.

C. Dress the newborn in ways to preserve warmth. D. Take the newborn's temperature often. E. Supply oxygen for the newborn, if necessary.

The nurse is assessing 2-year-old twins. The parent states, "My twins will not play together, only alongside each other." Which action will the nurse take first? A. Encourage the toddlers to play to allow for observation. B. Document the finding in the medical records. C. Explain that this is normal behavior for toddlers. D. Determine when this form of play was first noted.

C. Explain that this is normal behavior for toddlers.

General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks? A. The client is more sensitive to preanesthetic medications. B. The client is less sensitive to inhalation anesthetics. C. Neonatal depression is possible. D. Fetal hypersensitivity to anesthetic is possible.

C. Neonatal depression is possible.

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding? A. The uterine placement is normal. B. The uterus is filling up with blood. C. The bladder is distended. D. There is an infection inside the uterus.

C. The bladder is distended.

A nurse is reading a journal article about adolescents and major causes of injuries in this age group. The nurse demonstrates understanding of this information by identifying which situation as the major cause of adolescent injuries? A. suicide B. drowning C. motor vehicle crashes D. violence

C. motor vehicle crashes

The use of breast milk for premature neonates helps prevent which condition? A. Turner syndrome B. Down syndrome C. necrotizing enterocolitis D. Infantile respiratory distress syndrome

C. necrotizing enterocolitis

A teacher refers a student to the school nurse because the student is frequently falling asleep during class. After talking with the student, the nurse is most concerned by which statement by the student? A. "My mom keeps telling me to turn off my television when I go to bed." B. "I just can't seem to stay awake during that class because it's boring." C. "I guess I need to be more careful about my curfew on school nights." D. "I get 7 hours of sleep every night so I don't know why I am so tired."

D. "I get 7 hours of sleep every night so I don't know why I am so tired."

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? A. Test a sample of amniotic fluid for protein. B. Ask her to bear down with the next contraction. C. Elevate her hips to prevent cord prolapse. D. Assess fetal heart rate for fetal safety.

D. Assess fetal heart rate for fetal safety.

A 13-month-old child is brought to the clinic for a well-child visit. The child's parent expresses concern that the child has not started to walk yet. What is the best action should the nurse take? A. Explain that the child could start walking any day. B. Ask the parent if the child has been ill recently. C. Refer the child to a developmental specialist for evaluation. D. Explain that children can take their first steps as late as 18 months of age.

D. Explain that children can take their first steps as late as 18 months of age.

A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction? A. Change the perineal pad every 3 to 4 hours to decrease the uterine infection. B. Drink plenty of fluids to decrease a bladder infection. C. Apply ice to the perineum to decrease pain of a perineal infection. D. Finish all antibiotics to decrease a genital tract infection.

D. Finish all antibiotics to decrease a genital tract infection.

What foods could a parent provide that would be the most beneficial to support healthy dentition for a school-aged child? A. Bagels and cream cheese with sherbet B. Chicken sandwich with pretzels and apple juice C. Hamburger and a cherry Coke D. Fish, spinach salad and a glass of milk

D. Fish, spinach salad and a glass of milk

An 8-year-old male child is being seen for a well-child visit. His weight at his visit last year was 50 lb (22.7 kg) and his height was 47 in (119 cm). If he is developing normally, which finding will the nurse expect to note this year? A. Weight 62 lb (28.1 kg) B. The child has all of his adult teeth present. C. The child's weight is seven times his birth weight. D. Height 49.5 in (124 cm)

D. Height 49.5 in (124 cm)

A preschool-age child tells the nurse about an imaginary friend. The parents are concerned because the child refuses to do anything without the friend's help. Which nursing diagnosis is most applicable for the family? A. Disturbed thought processes related to deep-set psychological need B. Compromised family coping related to abnormal behavior of child C. Social isolation related to unwillingness to relate except through imaginary friend D. Parental anxiety related to lack of understanding of childhood development

D. Parental anxiety related to lack of understanding of childhood development

A female client tells the nurse about noticing an increase in weight and fat deposits during the past year. The nurse reviews the client's chart and recognizes that the client is most likely going through puberty. Which nursing action is most appropriate at this time? A. Encourage increased exercise to control weight gain. B. Review dietary measures to assist in controlling weight gain. C. Share what foods can be eaten on a low-fat diet to prevent fat deposits. D. Provide reassurance that these are normal changes.

D. Provide reassurance that these are normal changes.

The nurse is providing education to a teen mother about her 20-month-old daughter's growth. The teen says her daughter seems to have such a big head. What information should the nurse include in the response? A. Explain that the child looks normal. B. Teach the mother that this larger head than body appearance will be this way until the child is about 6 years old. C. Some children have large heads but that does not signal a problem. D. Share that the heads of children at this age are large in proportion to the rest of their body.

D. Share that the heads of children at this age are large in proportion to the rest of their body.

In discussing their 2-year-old's behavior with the nurse, which of the parents' statements suggests the child may be ready for toilet teaching? A. The child frequently repeats words parents just said. B. The child often removes her shoes and socks. C. The toddler walks with a wide, swaying gait. D. The child hides behind her bedroom door when defecating.

D. The child hides behind her bedroom door when defecating.

The nurse should carefully monitor which neonate for hyperbilirubinemia? A. neonate with Apgar scores 9 and 10 at 1 and 5 minutes B. neonate of African descent C. neonate of an Rh-positive mother D. neonate with ABO incompatibility

D. neonate with ABO incompatibility

During the second stage of labor, a woman is generally: A. very aware of activities immediately around her. B. anxious to have people around her. C. no longer in need of a support person. D. turning inward to concentrate on body sensations.

D. turning inward to concentrate on body sensations.

Four weeks before the birth of a client's already large child, the health care provider has told the client that if the baby gets bigger and the baby's lungs are ready, a cesarean birth is preferred. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse? A. "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress." B. "The procedure isn't risky for the baby, but your healing takes longer, and you'll have a scar." C. "Some women don't have any problem giving birth to large babies. You might want to get a second opinion." D. "If the health care provider has recommended the procedure, it's likely that the benefits outweigh the risks."

A. "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress."

The mother of a 6-year-old is asking the nurse how to handle the child's lying and fabricated stories when confronted with questionable actions. Which response would be most appropriate by the nurse? A. "Children this age sometimes can't distinguish between fantasy and reality." B. "Your child could be in serious trouble in school if he continues to tell lies." C. "Is there any possibility he is telling the truth and you just don't know it is the truth?" D. "The child should have privileges taken away for several days each time he tells a lie."

A. "Children this age sometimes can't distinguish between fantasy and reality."

A nurse is assigned the task of educating a pregnant client about birth. Which nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive birth experience? Select all that apply. A. Provide the client clear information on procedures involved. B. Encourage the client to have a sense of mastery and self-control. C. Encourage the client to have a positive reaction to pregnancy. D. Instruct the client to spend some time alone each day. E. Instruct the client to begin changing the home environment.

A. Provide the client clear information on procedures involved. B. Encourage the client to have a sense of mastery and self-control. C. Encourage the client to have a positive reaction to pregnancy.

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? A. Radiates from the back to the front B. Slows when the woman changes position C. Occurs in an irregular pattern D. Lasts about 20 to 25 seconds

A. Radiates from the back to the front

What activity would best foster the developmental task of an adolescent who uses a wheelchair to ambulate? A. Talking to another adolescent who has a similar situation B. Having a teacher bring school work to the adolescent C. Allowing the adolescent to decide when to bathe D. Watching television on the set in the adolescent's room

A. Talking to another adolescent who has a similar situation

At birth, the newborn was at the 8th percentile with a weight of 2350 g and born at 36 weeks' gestation. Which documentation is most accurate? A. The infant was a preterm, low-birth-weight and small-for-gestational-age B. The infant was born at term but at a low birth weight and small-for-gestational age C. The infant was born at term but at a very low birth weight and small-for-gestational-age D. The infant was a preterm, very-low-birthweight and small-for-gestational-age

A. The infant was a preterm, low-birth-weight and small-for-gestational-age

The physician has made a notation in the medical record of a 17-year-old that the teen is not demonstrating successful completion of Erikson's stages of development. What behavior would be consistent with this assessment? A. The teen is uncertain and frequently unable to make decisions. B. The teen is sexually promiscuous. C. The teen is anxious to move away from his parent's home. D. The teen is distrustful of others.

A. The teen is uncertain and frequently unable to make decisions.

The nurse is providing health-promotion teaching to a group of parents of preschoolers at a local day care. What information would the nurse include in this education session? Select all that apply. A. Treat any toileting accidents in a matter-of-fact manner and assist the child in getting dry clothing. B. Parents will need to supervise tooth-brushing and be responsible for flossing. C. Preschoolers only need to wear bicycle helmets if they are going on long rides. D. Preschoolers are capable of taking a bath independently. E. Encourage children to select their own clothing to wear each day.

A. Treat any toileting accidents in a matter-of-fact manner and assist the child in getting dry clothing. B. Parents will need to supervise tooth-brushing and be responsible for flossing. E. Encourage children to select their own clothing to wear each day.

The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process? A. Use a birthing ball and find a position of comfort. B. Stay low on her back to ease the back pain. C. Use the Valsalva maneuver for effective pushing. D. Ask for privacy, and have just the partner present.

A. Use a birthing ball and find a position of comfort.

A birth room nurse notes the presence of thick green amniotic fluid with the rupture of membranes during a vaginal birth. What nursing action is a priority at this time? A. Wipe the nares and then posterior pharynx immediately and gently. B. Vigorously suction the pharynx until there is strong newborn crying. C. Repeat pharyngeal suctioning and stimulation of the newborn. D. Perform pharyngeal suctioning with intubation.

A. Wipe the nares and then posterior pharynx immediately and gently.

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts? A. applying ice B. restricting fluids C. applying warm compresses D. administering bromocriptine

A. applying ice

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? A. asymmetrical movement B. temperature instability C. seizures D. feeble sucking

A. asymmetrical movement

When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn? A. during the first 24 hours of life B. between 2 and 4 days of life C. after 5 days postpartum D. often with formula-fed babies

A. during the first 24 hours of life

The nurse is caring for a pregnant woman who is struggling with controlling gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus? A. grow to an unusually large size B. have a serious birth defect C. suffer from asymmetrical intrauterine growth restriction D. suffer from symmetrical intrauterine growth restriction

A. grow to an unusually large size

During an extended initial resuscitation, what additional complications may be experienced by the infant during the resuscitation? Select all that apply. A. hypoglycemia B. dehydration C. hypokalemia D. anemia E. leukocytosis

A. hypoglycemia B. dehydration

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching? A. "If my lochia increases, I need to call my health care provider." B. "I should brush my teeth vigorously to stimulate the gums." C. "I need to avoid using any aspirin-containing products." D. "If I get a cut, I need to apply direct pressure for about 5 minutes or more."

B. "I should brush my teeth vigorously to stimulate the gums."

During an extended stay in a hospital the nurse has observed a 5-year-old having several temper tantrums. How should the nurse address this behavior with the parents? A. "We don't allow children of this age to throw tantrums so you will need to manage your child's behavior." B. "Is it common for your child to throw temper tantrums at home? We have observed this behavior several times here." C. "I am concerned that your child may have a developmental delay since most children of this age don't throw temper tantrums." D. "I think we need to plan how to discipline your child when acting out this way."

B. "Is it common for your child to throw temper tantrums at home? We have observed this behavior several times here."

A 10-year-old child tells the school nurse that she is embarrassed that she is afraid of the dark. Which is the best response by the nurse? A. "I was afraid of the dark at your age. You will grow out of that fear soon." B. "It is normal for a 10-year-old to be afraid of the dark so there is no need to be embarrassed. Would you like to talk about it?" C. "Are you afraid that something is going to happen to you or that something or someone may be outside that you can't see?" D. "That is so horrible that you are afraid of the dark. Can you sleep at night at all?"

B. "It is normal for a 10-year-old to be afraid of the dark so there is no need to be embarrassed. Would you like to talk about it?"

A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate? A. "Your cervix thins so that your contractions can increase." B. "You need the cervix to thin so it can stretch more easily." C. "It thins to let your baby change positions during labor." D. "Cervical thinning is a sign that you are in true labor."

B. "You need the cervix to thin so it can stretch more easily."

A 3-year-old child is hospitalized. The parents are concerned because the child is now refusing to use the potty and is wetting the bed even though the child has achieved toilet training. Which response by the nurse is most appropriate? A. "Why do you believe your child is refusing to use the potty?" B. "Your child is experiencing regression as a result of stress." C. "Do not worry. This is a normal response to being in the hospital." D. "Once discharged, your child will quickly learn to use the toilet again."

B. "Your child is experiencing regression as a result of stress."

While observing a 13-month-old and her parents in the playroom of the hospital unit, the nurse notes that the toddler is using her index finger to point towards a toy. What should the nurse say to the parents? A. "How long has your daughter used her index finger to point to objects?" B. "Your daughter is demonstrating fine motor skills appropriate to her age by pointing with her index finger." C. "I notice your daughter is using her index finger to point. This is something we should tell the doctor." D. "Has your daughter started turning book pages on her own yet."

B. "Your daughter is demonstrating fine motor skills appropriate to her age by pointing with her index finger."

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock? A. tachypnea and a widening pulse pressure B. tachycardia and a falling blood pressure C. bradycardia and auscultation of fluid in the base of the lungs D. bradypnea and hypertension

B. tachycardia and a falling blood pressure

At a physical examination, a nurse asks the father of a 4-year-old how the boy is developing socially. The father sighs deeply and explains that his son has become increasingly argumentative when playing with his regular group of three friends. The nurse recognizes that this phenomenon is most likely due to: A. regression. B. testing and identification of group role. C. playing in an even-number group of children (four). D. preschoolers having a harder time sharing than toddlers.

B. testing and identification of group role.